RN Clinical Documentation Specialist

TEKsystems • Milwaukee, WI

7d • $35 - $41 • Remote

About The Position

This will be a 6-9 month set contract needed to support automation within the business office. Contract needs may extend longer. 100% remote role; but must sit in Iowa, Illinois, or Wisconsin. Searching for an RN who has 2-3 years working as a Clinical Documentation Integrity RN in the acute care inpatient setting with experience in the adult patient population. You need to have experience collaborating with other clinicians, coding staff, and CDI leaders on medical records/charting to help improve data integrity. Epic experience is also required. The Clinical Documentation Specialist (CDS) is responsible for performing concurrent review of medical records to ensure complete and accurate clinical documentation to support severity of illness, risk of mortality for outcomes reporting, and for hospital reimbursement. The position requires a strong attention to detail and process orientation and an ability to think globally about documentation requirements in the medical records. The CDS must communicate effectively in oral and written form to physicians and other clinicians to promote accurate and complete documentation during the patient’s course of care. CDS supports the hospital’s overall compliance efforts designed to ensure the accuracy of diagnosis and procedural coding, Diagnosis Related Group (DRG) assignment, severity of illness (SOI), and expected risk of mortality (ROM). This position is a highly demanding and not a relaxed work from home opportunity!

Requirements

• Registered Nurse Certification
• Clinical Documentation Integrity RN experience in an adult acute care setting - 3 years
• Experience collaborating with other clinicians, coding staff, and CDI leaders on medical records/charting to help improve data integrity
• Epic experience is also required.
• Work from home space required

Responsibilities

• Conducts reviews of designated medical records to facilitate the creation of a health record that accurately represents the acuity of the patient’s illness and the resources used to treat the patient by ensuring provider documentation supports all applicable diagnosis codes.
• Ensures assignment of the working DRG is supported by diagnostic and procedural findings from the medical record. This will include the identification of secondary diagnosis that may result in Complications and Co-morbidities (CC) and/or Major Complications and Co-morbidities (MCC) assignment.
• Utilizes a compliant query process per guidelines and policies and follows each query through closure including complete documentation of ongoing follow up and communication.
• Maintains integrity and compliance of medical record reviews, clinical documentation integrity documentation, and queries.
• Efficiently and effectively utilizes UnityPoint Health’s selected CDI software and processes (i.e. CDI worksheet and workflow, physician query, query and DRG reconciliation processes).
• Meets the minimum productivity and quality assurance standards established by the CDI department.
• Collaborates with coding staff and leaders for improved knowledge and understanding of coding guidelines.
• Collaborates with physicians and/or other hospital staff to coordinate work and resolve issues.
• Collaborates with Clinical Documentation Integrity leaders to provide feedback and receive work direction.
• Collaborates with other hospital departments as needed and directed by CDI leaders.

Benefits

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

What This Job Offers

• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees