RN Clinical Documentation Specialist

Ensemble Health Partners • Winchester, VA

20h • $80,000 • Hybrid

About The Position

Thank you for considering a career at Ensemble Health Partners! Ensemble Health Partners is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country. Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference! O.N.E Purpose: Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations. Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation. Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results. The Opportunity: CAREER OPPORTUNITY OFFERING: Bonus Incentives Paid Certifications Tuition Reimbursement Comprehensive Benefits Career Advancement This position starts at: $80,000. Final compensation will be determined based on experience. This is a hybrid position and candidates must be able to work in rotation on-site at Valley - Winchester Medical Center in Winchester, VA. The candidate will work on-site 2-3 times a year to provide physician education. By embodying our core purpose of customer obsession, new ideas, and driving innovation, and delivering excellence, you will help ensure that every touchpoint is meaningful and contributes to our mission of redefining the possible in healthcare. The CDI Specialist facilitates and obtains appropriate physician documentation for any patient clinical condition or procedure to support the appropriate severity of illness, expected risk of mortality, and complexity of care as documented in patient medical records. Extensive medical record review and interaction with physicians, nursing staff, other patient care givers and HIM coding professionals is done to ensure the documentation is complete and accurate.

Requirements

• Licensed Registered Nurse
• Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, or Emergency Department experience
• Excellent interpersonal skills including verbal and written communication skills
• Ability to conduct brief presentations to a variety of audiences in clinical space
• Flexibility in assignments and workloads based on team needs
• Ability to organize and present information clearly and concisely
• Excellent computer and keyboarding skills
• High degree of prioritization skills

Responsibilities

• Completes timely initial and concurrent reviews of the patient medical record for Diagnosis Related Group (DRG) and documentation integrity utilizing CDI Software
• Assigns working Principal diagnosis, complication and comorbidity/major complication and comorbidity (CC/MCC), evaluate for Severity of Illness (SOI) and Risk of Mortality (ROM) on all reviews within CDI scope.
• Clarifies, based on industry standards, with providers regarding missing, unclear, unsupported or conflicting medical record documentation per regulatory guidelines
• Educates key healthcare providers such as physicians, nurse practitioners, allied health professionals, nursing and care coordination regarding clinical documentation improvement, documentation guidelines and the need for accurate and complete documentation in the health record.
• Partners with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine the working and final DRG assignment.
• Collaborates with care coordination, nursing staff and other ancillary staff regarding interaction with physicians on documentation and to resolve physician clarifications prior to patient discharge.
• Maintains and upholds all clinical documentation regulatory guidelines
• Applies clinical knowledge to educate and collaborate with stakeholders on standards for documentation and to look for opportunities of improvement based on review trends related to quality initiatives and value based purchasing.
• Maintains competency and accuracy in use of CDI software programs
• Conducts retrospective reviews for Mortality, Hospital Acquired Conditions (HAC) and Patient Safety Indicators (PSI) accounts.
• Demonstrates knowledge of ICD-10 and Procedure Coding System (PCS) codes, requirements, and sequencing and DRG assignment as well as clinical documentation requirements.

Benefits

• Bonus Incentives
• Paid Certifications
• Tuition Reimbursement
• Comprehensive Benefits
• Career Advancement
• Associate Benefits – We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.
• Growth – We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement.
• Recognition – We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company.

What This Job Offers

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