RN Clinical Documentation Informaticist - Remote (see full posting for eligible states)

Northern Arizona Healthcare • Flagstaff, AZ

17d • Remote

About The Position

The Clinical Documentation Information Specialist facilitates complete and comprehensive clinical documentation that reflects clinical treatment, diagnosis, severity of illness, and risk of mortality. The role works with a multidisciplinary team, including physicians, HIM coders, and Physician Advisors, to clarify and improve documentation and support appropriate MS-DRG assignment. The specialist conducts concurrent and retrospective reviews, identifies diagnoses and procedures that reflect patient severity and risk, audits documentation, and maintains accurate tracking data to identify trends and support team goals. The position also requires compliance with applicable regulations, company policies, safety practices, and required training.

Requirements

• Associate degree with RN, RHIA/RHIT, or a bachelor's degree with experience/certification in Coding/CDI.
• Current RN license; it does not have to be from Arizona.
• CCDS certification required after two years of experience.
• Understand computers and demonstrate competence using computers and basic software programs.

Nice To Haves

• BSN preferred.
• 3–5 years of clinical documentation specialist, coding, or UR experience preferred.
• Supervisory, education, or leadership experience preferred.

Responsibilities

• Demonstrate understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnoses, and the impact of procedures on DRG; share this knowledge with physicians and other health team members.
• Apply guidelines of care and practice through the nursing process and in accordance with Arizona State Board of Nursing Laws and Regulations.
• Maintain a review rate of 80% and a query rate of 15% on assigned cases, or as determined by clinical performance need.
• Audit documentation to ensure consistency and that standards are met.
• Communicate with physicians face-to-face or through clinical documentation inquiry forms to clarify information, obtain needed documentation, present opportunities, and educate about appropriate MS-DRG based on severity of illness.
• Confer with HIM coders to ensure appropriate MS-DRG assignment and complete supporting documentation.
• Confer with a Physician Advisor as needed.
• Conduct concurrent and retrospective reviews of assigned patients at the required time frame and frequency.
• Identify and record the most appropriate principal diagnosis, secondary diagnoses, complications/co-morbidities, and procedures to reflect severity of illness and risk of mortality.
• Identify opportunities to improve documentation processes.
• Maintain accurate tracking-database data to identify trends and issues and develop action plans to achieve team goals.
• Report safety-related incidents promptly through the Midas/RDE tool, attend safety training, work safely, monitor the work environment for potential safety issues, and ensure others work safely.
• Stay current with and comply with state and federal regulations/statutes and company policies affecting the employee's area of responsibility.
• Keep required certifications and licenses current and valid before expiration, if required for the position.
• Complete mandatory company modules and required job-specific training within the specified time frame.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree