RN Clinical Documentation Specialist

Care Synergy • Denver, CO

58d • Onsite

About The Position

The Denver Hospice has an opening for an RN Clinical Documentation Specialist. This role is responsible for reviewing patient medical records to ensure they meet clinical, regulatory, and billing compliance standards. It combines clinical expertise with a deep understanding of healthcare regulations, including those from the Centers for Medicare and Medicaid Services (CMS). The specialist will conduct thorough reviews of clinical documentation, identify missing or conflicting information, and ensure adherence to federal and state regulations. They will also analyze audit findings, generate reports, and educate clinicians on proper documentation procedures. This role is crucial for maintaining compliance and driving continuous improvement in documentation quality.

Requirements

• Graduate of an accredited school of nursing.
• 2 years’ experience with electronic health records (EHRs) and auditing software is necessary.
• Proficiency with basic computer programs, including the Microsoft Office suite, is also required.
• Excellent written and verbal communication skills are critical for reporting findings and providing feedback to staff.
• Strong analytical and critical-thinking skills are needed to research complex coding and compliance issues.
• Current Colorado RN license or a license from the state of primary residence, if participating in the NLC (Nurse Licensure Compact).

Nice To Haves

• 5 years’ experience in hospice or home health medical record review, medical terminology, and relevant regulations, including Medicare and Medicaid rules is preferred.
• OASIS D and ICD-10 certification is preferred but may be substituted for actual hands-on experience.

Responsibilities

• Responsible for reviewing patient medical records to ensure they meet clinical, regulatory, and billing compliance standards.
• Conducts thorough reviews of clinical documentation during the patients’ stay, often within 24-48 hours of admission, such as patient charts, care plans, and physician's orders, to ensure they are complete, accurate, and support the patient's initial and ongoing eligibility for hospice services.
• Identifies missing, vague, or conflicting documentation regarding a patient’s condition and treatment and works closely with physicians and other providers to gain clarity or obtain additional information.
• Verifies that all records and billing practices adhere to applicable federal and state regulations, including CMS and HIPAA standards.
• Analyzes audit findings to identify trends and patterns in documentation quality.
• Generates quality reports and presents findings to clinical staff and leadership to facilitate continuous improvement.
• Educates clinicians and other staff on proper documentation procedures, compliance essentials, and best practices.
• May help develop training materials for staff development.
• Assists in preparing for internal and external audits, including those from regulatory bodies like the Office of Inspector General (OIG), Accreditation Commission for Health Care (ACHC) & Colorado Department of Public Health and Environment (CDPHE).
• Ability to critically appraise hospice patient charts and determine if they are in compliance.
• Translate audit findings and trends into organizational improvement activities.
• Create and deliver educational offerings, team member coaching, etc., from chart findings to drive improvement.

Benefits

• Employer pays over 90% of employee medical premium in some plans
• Health Savings Account (HSA) with significant Employer Funding: Single $1,000, Family $2,000
• Extensive Paid Time Off (PTO/Vacation Pay/Sick Leave): 18 days in the first year for FT team members
• Seven Paid Holidays with an additional Floating Holiday
• 403(b) Retirement Plan with Employer Match: 50% match up to 8% of total compensation
• Company-Paid Life and AD&D Insurance
• Career & Logo wear
• Education Reimbursement Program
• Clinical Career Ladders
• Certification Pay
• Generous Discover-a-Star Team Member Referral Program
• Team Member Service Awards
• Early Wage Access
• Legal and Identity Protection
• Robust Leadership Development Training Programs

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level