DescriptionClinical Documentation Specialist RNLocation: Colorado. 100% remote/work-from-home position. Eligible out-of-state candidates may be considered.
Department: Clinical Documentation Integrity
FTE: PRN, 0.0, 0.00 hours per pay period (2 weeks)
Shift: Days
Pay: $37.06 - $57.44 / hour. Pay is dependent on applicant's relevant experience
Summary:Performs concurrent review of clinical documentation in written and electronic medical records to ensure compliant, appropriate and accurate reimbursement based on severity of patient illness, risk of mortality and level of services provided to patients. Collaborates with physicians, nursing staff, ancillary departments, and coding staff to ensure clinical documentation is compliant, complete and accurate. Provides ongoing education and support to the healthcare team in regard to clinical documentation in the medical record.
2 years of CDI experience is required for this position.Responsibilities:- Reviews inpatient medical records for areas of opportunity regarding clinical documentation of diagnosis and procedures to assign a working DRG for identified population. Conducts reviews and documents findings.
- Identifies need to clarify documentation in records; communicates with providers to capture documentation that supports the severity of illness and risk of mortality. Conducts follow up reviews for responses to physician queries. Serves as a resource to physicians and staff.
- Works with coding staff to assure documentation of diagnoses and comorbidities or complications are a complete reflection of the patient's clinical status and care.
- Maintains knowledge of requirements and guidelines to include changes/updates to practice or requirements.
Requirements:- Graduate of an accredited or state board of nursing approved Registered/Professional Nursing program.
- CO State licensure as a Registered Nurse (RN).
- 5 years of recent clinical experience in an acute inpatient nursing unit OR current work experience that requires communication with providers, with 5 years of nursing in an acute care facility.
Preferred:- Bachelor's Degree in Nursing.
- Critical care and MED/SURG background with the ability to assess and identify relevant acute and chronic medical conditions.
- CCDS or CDIP certification.
- 2+ years of CDI experience.
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