clinical documentation consultant

The University of Iowa

<div>The Clinical Documentation Improvement (CDI) program at UI Health Care has an opening for a full-time Clinical Documentation Specialist. The primary purpose of Clinical Documentation Improvement (CDI) is concurrent review of the medical record to increase the accuracy, clarity, and specificity of provider documentation (Association of Clinical Documentation Improvement Specialists, ACDIS).
Clinical Documentation Specialists bridge the gap between the providers and hospital coders to clarify at-risk documentation to ensure accurate claim submission (American Health Information Management Association, AHIMA). CDI chart reviews include:<ul><li>
New acute inpatient admissions to the facility</li><li>
Identifies and re-reviews high priority charts every two days or as needed</li><li>
Retrospective reviews for query identification, documentation clarification, denials, or quality measures.</li><li>
Completes quality reviews focused on CDI quality elements, such as Mortality, Hospital Acquired Conditions (HAC), and other publicly reported patient quality or safety metrics (i.e., AHRQ Patient Safety Indicators)</li></ul>
When provider documentation is illegible, incomplete, imprecise, inconsistent, conflicting, or unreliable the Clinical Documentation Specialist is expected to communicate (i.e., query) with the provider to obtain the necessary information to clarify the medical record (AHIMA, 2014).
The Clinical Documentation Specialist must hold a general proficiency within both the clinical and hospital coding skill sets. The Clinical Documentation Specialist provides the geometric mean length of stay (GMLOS) associated with the working DRG to identify the expected length of stay for acute inpatients.
The successful candidate will have:<ul><li>
A bachelor&rsquo;s degree in nursing or a master&rsquo;s degree in nursing (MNHP or MSN)</li><li>
An Iowa nursing license</li><li>
Three years of recent inpatient nursing experience in a medical-surgical, and/or ICU setting, and/or recent work experience as a Clinical Documentation Specialist, CDI nurse, or healthcare quality professional with specific medical record review experience</li><li>
Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire.</li><li>
Applicants must upload a current resume and a cover letter that clearly address how they meet the listed required and desired qualifications of this position.</li></ul>
Initial training and onboarding will take place at the Healthcare Support Services Building (HSSB), 3231 Ridgeway Drive, located in Coralville, IA 52241. This position is eligible to participate in 100% remote work after the initial training and onboarding has been completed. Remote work must be performed at a location within the state of Iowa and will require a work arrangement form to be completed upon the start of your employment. Per policy, work arrangements will be reviewed annually, and must comply with the remote work program and related policies and the employee travel policy when working at a remote location.
Job Duties and Responsibilities:<ul><li>
Establishes effective and collaborative relationships with members of the hospital community to improve accuracy and completeness of acute inpatient documentation, especially with providers, Health Information Management coding staff, hospital administration, and other patient caregivers.</li><li>
Demonstrate knowledge of MS-DRGs, APR-DRGs, documentation opportunities, clinical documentation requirements, and inpatient quality/safety metrics.</li><li>
Consistently attends huddles or rounds on units, as directed by department leadership.</li><li>
Provides consistent education on clinical documentation opportunities, hospital coding and/or reimbursement issues, as well as performance improvement methodologies to all members of the hospital community.</li><li>
Conduct record reconciliation and communicates effectively with hospital coding staff to assign an appropriate working DRG.</li><li>
Documents appropriately in the 3M&copy; Clinical Documentation Improvement module.</li><li>
Demonstrates an understanding of the importance of capturing all potential secondary diagnosis for coding purposes.</li><li>
Maintains thorough and current knowledge of clinical care and treatment of assigned patient populations to critically assess appropriateness of documentation.</li><li>
Comply with departmental standards regarding attendance, documentation, departmental workflows, continuous quality improvement and statistics, departmental policies and procedures, and the Code of Ethics.</li><li>
Effectively collaborates and respectfully communicates with fellow CDI team members, the hospital coding team, and quality-driven workgroups to ensure appropriate CDI practices and accurate application of coding/documentation principals.</li><li>
Actively participate in office and/or intradepartmental committees.</li><li>
Performs other projects or responsibilities as assigned.</li></ul>
Percent of Time: 100% (full-time)
Work schedule: Some flexibility between the hours of 7:00 AM and 5:00 PM, Monday through Friday.
Location: Initial onboarding and training will be completed at the Healthcare Support Services Building (HSSB), located at 3231 Ridgeway Drive in Coralville, IA 52241. This position is eligible to participate in 100% remote work after the initial training and onboarding has been completed. Remote work must be performed at a location within the state of Iowa and will require a work arrangement form to be completed upon the start of your employment. Per policy, work arrangements will be reviewed annually, and must comply with the remote work program and related policies and the employee travel policy when working at a remote location.
Salary level 5A. Starting salary will be based on applicant qualifications and related/relevant experience. To view the full pay range for salary level 5A: Professional and Scientific Pay Structures | University Human Resources - The University of Iowa.
Benefits Highlights: Fringe benefit package including paid vacation; sick leave; health, dental, life and disability insurance options; and generous employer contributions into retirement plans. Complete information regarding the full benefits package may be viewed at: https://hr.uiowa.edu/benefits.
<div>Required Qualifications:<ul><li>
A bachelor&rsquo;s degree in nursing or a master's degree in nursing (MNHP or MSN) is required.</li><li>
A current license to practice nursing in Iowa is required.</li><li>
Three years of recent (within the last 10 years) of inpatient nursing experience in a medical-surgical, and/or ICU setting, and/or recent work experience as a Clinical Documentation Specialist, CDI nurse, or healthcare quality professional with specific medical record review experience are required.</li><li>
Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire.</li><li>
Professional written and verbal communication skills are required</li><li>
Demonstrates the ability to provide effective education in a variety of styles, including formal presentations.</li><li>
Proficiency with computer software applications (i.e., Microsoft applications) is required</li><li>
Demonstrates excellent interpersonal skills with physicians, nursing staff, and interdisciplinary team members as demonstrated through written and verbal communication is required.</li><li>
Demonstrated organizational, time management and problem-solving skills are required.</li></ul> 
Desired Qualifications:
<ul><li>Experience with performance improvement methodologies</li><li>
Experience improving and/or reviewing hospital quality/safety metrics</li><li>
Experience with data mining and/or data analytics</li><li>
Advanced certification (i.e., CCDS, CDIP, CPHQ)</li></ul>
Application Process:<ul><li>
To be considered for an interview, applicants must upload a current resume and a cover letter that clearly address how they meet the listed required and desired qualifications of this position.</li><li>
Job openings are posted for a minimum of 7 calendar days. Applications will be accepted until 11:59 PM on March 25, or on date of closing.</li><li>
Successful candidates will be required to self-disclose any conviction history and will be subject to a criminal background check.</li><li>
Professional references will be requested at a later step in the recruitment process.</li><li>
This position is not eligible for University of Iowa sponsorship for employment authorization.</li><li>
For questions, contact Heidi Bodensteiner at heidi-bodensteiner@uiowa.edu.</li></ul></div></div>

Clinical Documentation Specialist

TriHealth Inc.

<div><div>Join Our Team as a Clinical Documentation Specialist II! 
Join TriHealth as a Clinical Documentation Specialist II and partner with interdisciplinary teams to improve documentation accuracy, support quality outcomes, and elevate patient care. Apply today and be part of a team that is passionate about making a difference. 
We offer career growth opportunities, and a comprehensive benefits package. 
Location:<ul><li>
Remote</li><li>
This position requires in‑person attendance for scheduled onsite meetings; therefore, candidates must be located within the greater Cincinnati area.</li></ul> 
Work Schedule:<ul><li>
Full time</li><li>
Day shift</li><li>
No weekend or holiday rotation required</li></ul> 
Incentives &amp; Benefits:
We offer a comprehensive benefits package, including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement.
https://careers.trihealth.com/what-we-offer/benefits 
Job Requirements:<ul><li>
Bachelor's Degree in Nursing; Business, Education, HIM,</li><li>
CCDS - Certified Clinical Documentation Specialist</li><li>
Registered Nurse</li><li>
Advanced CDI certification if available</li><li>
Computer aptitude including but not limited to electronic medical record clinical documentation software programs, Word, Excel and PowerPoint</li><li>
5-7 years experience Clinical Nursing</li><li>
2-3 years experience Clinical Documentation</li></ul> 
Job Overview:<ul><li>
The Clinical Documentation Specialist II reports to the Clinical Documentation Department Manager. This team member assists with the delivery of clinical documentation strategies within the workplace that positively impact and drive change to attain organizational goals as well as maintain documentation standards as set by government and corporate guidelines, The Clinical Documentation Specialist II requires an advanced level of knowledge and experience for the successful management of clinical education in their specialty area, quality monitoring, documentation review and the ability to communicate this knowledge to team members throughout the organization, including Medical Staff Departments. They will serve as a subject matter experts in their specialty field which includes but is not limited to preparing and presenting a minimum of two educational topics each calendar year for the benefit of the medical staff, APNs, residents and/or team members as well as being responsible for specialty specific orientation to new team members or those who need refreshers. They will participate in peer interviews and leadership opportunities such as serving on committees, leading journal club or conducting a review course for team members interested in certification. This position requires a professional who works well independently but also values team and possesses excellent communication skills.</li></ul> 
Job Responsibilities:<ul><li>
Documentation Improvement - record review rate of at least 98%. Severity clarification rate of at least 25%. DRG shift clarification rate of at least 15%. 
Provides Informal education includes sharing with team members in assigned patient care area, inpatient coding department and clinical documentation team advanced or new strategies for capturing highest level of SOI/ROM, denial prevention, and determining PSIs. Documentation of informal education with physicians, APNs, residents on documentation strategies and their importance.</li></ul><ul><li> 
Maintains specialty certification and pursue advanced CDI certification within 1 year of certification becoming available. A minimum of two formal presentations per year on pertinent advanced CDI topics at monthly team meetings, resident or medical staff meetings.</li></ul><ul><li> 
Participates in department or hospital committees such as Stroke Committee, Task Force, etc., new team member specialty orientation leader or participating as part of the peer interview team. Other options include but are not limited to leading a department journal club or participating in a minimum of 10 hours of approved community service per year.</li></ul> 
Other Job-Related Information:
This position requires excellent verbal and written communication skills as well as proficiency in the electronic medical record, clinical documentation software, word, excel and power point. Expectation is that the Clinical Documentation Specialist 2 will prepare a minimum of two educational topics to be shared with team members at staff meetings and/or physicians at staff meetings on topics related to advanced CDI. 
Working Conditions: 
Climbing - Occasionally 
Concentrating - Consistently 
Continous Learning - Consistently 
Hearing: Conversation - Occasionally 
Interpersonal Communication - Consistently 
Kneeling - Occasionally 
Lifting &lt;10 Lbs - Occasionally 
Lifting 50+ Lbs - Rarely 
Lifting 11-50 Lbs - Occasionally 
Pulling - Occasionally 
Pushing - Frequently 
Reaching - Frequently 
Reading - Consistently 
Sitting - Frequently 
Standing - Frequently 
Stooping - Occasionally 
Thinking/Reasoning - Consistently 
Use of Hands - Consistently 
Color Vision - Consistently 
Walking - Frequently<div> 
TriHealth SERVE Standards and ALWAYS Behaviors: 
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following: 
 
Serve: ALWAYS&hellip; 
<ul><li>Welcome everyone by making eye contact, greeting with a smile, and saying &quot;hello&quot;</li><li>Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist</li><li>Refrain from using cell phones for personal reasons in public spaces or patient care areas</li></ul></div><div> 
Excel: ALWAYS&hellip; 
<ul><li>Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met</li><li>Offer patients and guests priority when waiting (lines, elevators)</li><li>Work on improving quality, safety, and service</li></ul></div><div> 
Respect: ALWAYS&hellip; 
<ul><li>Respect cultural and spiritual differences and honor individual preferences.</li><li>Respect everyone&rsquo;s opinion and contribution, regardless of title/role.</li><li>Speak positively about my team members and other departments in front of patients and guests.</li></ul></div><div> 
Value: ALWAYS&hellip; 
<ul><li>Value the time of others by striving to be on time, prepared and actively participating.</li><li>Pick up trash, ensuring the physical environment is clean and safe.</li><li>Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.</li></ul></div><div> 
Engage: ALWAYS&hellip; 
<ul><li>Acknowledge wins and frequently thank team members and others for contributions.</li><li>Show courtesy and compassion with customers, team members and the community</li></ul></div> 
Job Keywords: Registered Nurse, Nurse, Clinical Documentation</div></div>

Clinical Documentation Specialist II

The University of Michigan

<div><h4 class="jobSectionHeader">Job ID: 53350</h4>
<h4 class="jobSectionHeader">Description:</h4>
<div>Positions Location: Lansing, MI<div> 
<h2 class="jobSectionHeader">
Job Description</h2>

General Purpose of Job:
The UMHP Clinical Documentation Specialist - Senior (CDS) serves as a subject matter expert in clinical documentation improvement and provider coding accuracy, for ambulatory Primary Care and Specialty Care services. This position provides advanced expertise, guidance, and education to physicians, APPs, and staff on documentation standards, CPT/ICD-10 and HCC coding, and compliance requirements. The CDS Senior focuses on analyzing complex documentation and coding issues, identifying opportunities for improvement, and coordinating with leadership on the development of best practices to ensure accurate charge capture.

Essential Duties:

This job description is intended to cover the minimum essential duties assigned on a regular basis. Team members may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.
<ul><li>Collaborates with key stakeholders on the design, implementation, education and evaluation of tools and resources to assist providers with efficient and effective documentation, accurate coding and charge capture opportunities. All coding edits and/or revisions including claim submission are the sole responsibility of the HIM and billing teams. All coding education will be approved by Compliance prior to implementation.</li>
<li>Provides partial coordination and project management of the Medical Group and Population Health&rsquo;s governance structure Councils, Committees and Offices.</li>
<li>Serves as a subject matter expert and supports fellow UMHP CDS team members.</li>
<li>Collaborates with key stakeholders on the facilitation and deployment of the UMHP CDS coding and documentation education strategy.</li>
<li>Collaborates with key stakeholders on the development of an upstream coding, documentation, charge capture, education approach focused on new departments and emphasizing new specialty areas to increase knowledge and establish sustainable best practices early on.</li>
<li>Provides support during the onboarding training and support for new physicians and APPs on documentation, coding and charge capture excellence, establishing a periodic check-in/assessment process and appropriate charge capture check-ins.</li>
<li>Collaborates with key stakeholder on communications with Primary Care site and Specialty Care service line leaders, physicians and APPs with regard to clinical documentation and medical coding for patient care services. Facilitates CDS interaction with site/service line provider champions.</li>
<li>Tracks ROI and collaborates with leadership on the preparation and analyzation of reports (ROI, Revenue Cycle, wRVU, etc.) to ensure operational alignment and buy-in and to provide feedback on provider and coding performance including state of documentation, charge capture and reconciliation.</li>
<li>In collaboration with the leadership and the UMHP CDS team, identifies ROI, documentation trends and priority areas/pain points to be shared with site/service line leadership to allow for clinician education. Prepares case and specific documentation examples/presentations to share at department meetings.</li>
<li>Reviews wRVU recovery data provides recommendations on areas to be prioritized.</li>
<li>Assists with UMHP and department initiatives to improve charge capture and reconciliation.</li>
<li>Supports the strategic development of outpatient charge capture optimization (i.e. professional clinical visits/services, surgeries, procedures and imaging studies), and facilitates change processes.</li>
<li>Identifies educational opportunities to improve and enhance learning. Maintains current with specialty coding updates, work processes, tools, and clinical and administrative applications necessary to perform job functions.</li>
<li>Serves as a resource on documentation requirements and ensures compliance with applicable laws and regulations at the direction of the internal audit team.</li>
<li>Builds and maintains positive working relationships throughout the organization that enable efficient leadership through projects involving change management or complex cross-departmental collaboration.</li>
</ul>
</div><div><h2 class="jobSectionHeader">Job Requirements</h2>
<div><div><div><div>General Requirements</div> <div>&bull; RHIT, RHIA, CCS, CCS-P, CPC or other professional HIM coding certificate &bull; EPIC or Revenue Cycle Certification &ndash; preferred &bull; Clinical Documentation certification &ndash; preferred
</div></div> 
<div><div>Work Experience</div> <div>&bull; At least five (5) years of experience with healthcare documentation, coding requirements, or revenue cycle coding experience &bull; At least one (1) year of experience as an educator or trainer in a healthcare setting &bull; Prior clinical experience &ndash; preferred &bull; Experience using EPIC &ndash; preferred
</div></div> 
<div><div>Education</div> <div>&bull; Associate degree in Business, Nursing, or related field; or equivalent experience in medical billing, coding, health information technology/management, health administration, business administration or another related field. &bull; Bachelor&rsquo;s degree in related field &ndash; preferred
</div></div> 
<div><div>Specialized Knowledge and Skills</div> <div>&bull; Extensive CPT and ICD-10 coding knowledge. &bull; Demonstrated experience providing documentation and coding education to providers. &bull; Excellent communication skills (verbal and written) to enable effective outcomes with the diverse complex clinical care teams. &bull; Ability to navigate the EHR to identify documents or review to provide accurate capture of clinical information. &bull; Medical terminology and clinical knowledge with the ability to review documentation and determine what documentation is needed to provide accurate medical codes. &bull; Ability to work independently, self-motivated and an ability to adapt to the changing healthcare environment. &bull; Demonstrates attention to detail, proficiency in organizational skills and planning with and ability to juggle multiple priorities in a fast-changing environment. &bull; Proficiency in computer use including Microsoft Office Suite experience. &bull; Provide support to clinicians on navigating all functions of the EHR. &bull; Possess initiative-taking, strategic, innovating and out-of-the-box thinking. &bull; Exhibit an understanding of health care administration, health industry trends. &bull; Demonstrates leadership, independence, responsibility, accountability and good judgment. Ability to think strategically. &bull; Acts as a self-starter and demonstrate a willingness to take on new and challenging leadership roles, as well as non-leadership projects and deliverables. &bull; Accepts and respects diversity without judgment.
</div>
</div> 
</div></div></div>University of Michigan Health - Sparrow is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veteran status.
</div><h4 class="jobSectionHeader">Job Family</h4>
Management/Professional
<h4 class="jobSectionHeader">Requirements:</h4>
<div><div><div><div>Shift </div><div>Days
</div></div> 
<div><div>Degree Type / Education Level </div><div>Associate
</div></div> 
<div><div>Status </div><div>Full-time
</div></div> 
<div><div>Facility </div><div>Match Any
</div></div> 
<div><div>Experience Level </div><div>4-9 Years</div></div></div></div></div>

UMHP-CLINICAL DOCUMENTATION SPECIALIST SENIOR

Trinity Health

<div>
 
 Employment Type
 
 
 
 Full time
 
 
 
 Shift
 
 
 
 Day Shift
 
 
 
 Description
 
 
 
 POSITION PURPOSE
 
 
 Work Remote Position
 
 
 (Pay Range:$41.4306-$62.1459)
 
 
 Provides onsite and remote clinical documentation integrity (CDI) support to the Health Ministry (HM) CDI programs as part of the System Office CDI Float Pool. Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement and integrity of clinical documentation.
 
 
 Responsible for reviewing and/or auditing medical record clinical documentation to support the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services rendered to all patients. Audits HM CDSs for query compliance, workflow and missed documentation opportunities. Trains end users in the use of CDI system software, standards, and workflow.
 
 
 
 Essential Functions
 
 
 
 Knows, understands, incorporates, and demonstrates Trinity Health's Mission, Vision, and Values in behaviors, practices, and decisions.
 
 
 Demonstrates understanding of and facilitates appropriate clinical documentation, to ensure that the medical necessity, severity of illness, risk of mortality, accurate coding, clinical evidence, resources consumed, and level of services provided are accurately reflected in the health record.
 
 
 Conducts clinical documentation chart reviews and queries providers as appropriate to support RHMs staffing needs. Reviews may be conducted on site or remotely.
 
 
 Follows HM CDI Program workflow and processes and communicates with local CDI Team to support local operations.
 
 
 Communicates with physicians and other members of the healthcare team at the HM regarding clinical documentation as part of local CDI Team assignment.
 
 
 Audits medical records, queries, CDS and coder assigned codes, CDI software entries, etc., as requested to provide feedback to the HMs for improvement opportunities.
 
 
 Trains end users in the use of CDI system software, standards, and workflow.
 
 
 Provides documentation education to providers and members of healthcare team at the RHM as part of CDI Team assignment or as requested.
 
 
 Demonstrates ability to quickly learn and master the various CDI technology applications, systems and workflows in place across the enterprise.
 
 
 Provides expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgment and serves as a professional role model by demonstrating desirable practice behaviors.
 
 
 Assists the System Office Clinical Documentation Manager with all aspects of the CDI program across the system including data collection and maintenance of the CDI Dashboard.
 
 
 May develop educational content for providers and CDSs on CDI workflow and processes, CDI and Physician software systems, and documentation and coding guidelines as requested.
 
 
 Performs other duties as assigned by leadership.
 
 
 Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health&rsquo;s Organizational Integrity Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
 
 
 
 Minimum Qualifications
 
 
 
 Must possess a minimum of one of the below:
 
 
 <ul>
 <li>
 Current Registered Nurse License,
 </li>
 <li>
 Registered Health Information Administrator (RHIA),
 </li>
 <li>
 Registered Health Information Technician (RHIT),
 </li>
 <li>
 Certified Coding Specialist (CCS)
 
 
 </li>
 </ul>
 Certification as a Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
 
 
 Experience in Clinical Documentation Integrity.
 
 
 Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Ability to educate all members of the healthcare team related to clinical documentation.
 
 
 
 Experience With Databases, Spreadsheet Software And Presentation Software Preferred.
 
 
 
 Must be comfortable operating independently in a collaborative, shared leadership environment.
 
 
 Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health
 
 
 
 Physical And Mental Requirements And Working Conditions
 
 
 
 Must be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles.
 
 
 Must possess the ability to comply with Trinity Health policies and procedures.
 
 
 Must be able to spend majority of work time utilizing a computer, monitor, and keyboard.
 
 
 Must be able to perform some lifting and/or pushing/pulling up to 20 pounds.
 
 
 Must be able to work with interruptions and perform detailed tasks.
 
 
 Must be able to work on different projects simultaneously and coordinate work to meet deadlines.
 
 
 Requires the ability to concentrate and read for long periods of time.
 
 
 Involves a wide array of physical activities, primarily walking, standing, balancing, sitting, squatting, and reading. Must be able to sit for long periods of time.
 
 
 
 The above statements are intended to describe the general nature and level of work being performed by persons assigned to this classification. They are not to be construed as an exhaustive list of duties so assigned.
 
 
 
 
 Our Commitment
 
 
 
 Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
</div>

Clinical Documentation Specialist Audit Coordinator (Remote)

Sutter Health

<div>We are so glad you are interested in joining Sutter Health!
Organization:
SHSO-Sutter Health System Office-Valley
Position Overview:
Conducts concurrent and retrospective reviews of patient medical records to evaluate the accuracy and completeness of clinical documentation, ensuring notes reflect the severity of patient's illness and quality of care. Interacts thoughtfully and effectively with physicians, patient care team, and ancillary departments to gather and clarify medical record documentation. Identifies opportunities for improvement to ensure understanding of documentation requirements, optimize reimbursement for the level of service rendered, and enhance the measurement and reporting of outcomes.
Job Description:
EDUCATION:<ul><li>
Graduate of an accredited school of nursing OR Foreign trained physician</li></ul> 
CERTIFICATION &amp; LICENSURE:<ul><li>
RN-Registered Nurse of California OR Foreign trained physician</li></ul> 
TYPICAL EXPERIENCE:<ul><li>
5 years recent relevant experience.</li><li>
CDIP or CCDS preferred</li></ul> 
SKILLS AND KNOWLEDGE:<ul><li>
Clinical knowledge of diagnoses, severity of illness, risk of mortality, co-morbidities and complications.</li><li>
Knowledge of age-specific needs and the elements of disease processes and related procedures.</li><li>
Knowledge of current coding classification and reimbursement guidelines and regulations.</li><li>
Critical thinking with the ability to analyze and interpret medical record/clinical documentation and formulate appropriate physician queries.</li><li>
Ability to define issues, collect data, establish facts and draw valid conclusions.</li><li>
Demonstrates a proactive approach in identifying and addressing issues and concerns.</li><li>
Collaboration skills to facilitate open sharing of information and cooperation with various stakeholders to problem solve and achieve desired results/outcome.</li><li>
Displays a customer service focus in all decisions and actions.</li><li>
Ability to communicate through verbal and written means, and to present information to a variety of audiences.</li><li>
Ability to create and translate data into reports and presentations for appropriate audience.</li><li>
Organization skills to effectively manage and/or re-prioritize activities and projects to meet deadlines while maintaining a high degree of responsiveness.</li><li>
Ability to interact and maintain effective working relationships with those contacted in the performance of required duties.</li><li>
Demonstrates respect for cultural and linguistic differences and promotes an inclusive work environment.</li><li>
Demonstrates initiative in providing feedback/input to improve workflow/processes.</li><li>
Ability to work effectively in a dynamic and fast-paced environment with changing business priorities.</li><li>
Ability to maintain and work discreetly with confidential information.</li><li>
Ability to use essential applications and/or databases associated with the role&rsquo;s duties and responsibilities.</li></ul> 
Job Shift:
Days
Schedule:
Full Time
Shift Hours:
8
Days of the Week:
Monday - Friday
Weekend Requirements:
None
Benefits:
Yes
Unions:
No
Position Status:
Non-Exempt
Weekly Hours:
40
Employee Status:
Regular
Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.
Pay Range is $82.86 to $108.54 / hour. Pay Transparency Name New Jersey, Washington Pay Range is $79.32 to $103.87 / hour. Colorado, Florida, Georgia, Illinois, Michigan, Minnesota, Nevada, North Carolina, Ohio, Oregon, Pennsylvania, Texas, Virginia Pay Range is $41.00 to $53.83 / hour. Arizona, Arkansas, Idaho, Louisiana, Missouri, Montana, South Carolina, Tennessee, Utah Pay Range is $37.37 to $48.94 / hour.
The compensation range may vary based on the geographic location where the position is filled. Total compensation considers multiple factors, including, but not limited to a candidate&rsquo;s experience, education, skills, licensure, certifications, departmental equity, training, and organizational needs. Base pay is only one component of Sutter Health&rsquo;s comprehensive total rewards program. Eligible positions also include a comprehensive benefits package.</div>

Clinical Documentation Specialist, Clinician

ACMH Hospital

<div><div><div><div><div>Job Type:</div> <div>Full Time</div>
</div> 
<div><div>Department:</div> <div>Administration</div>
</div> 
</div></div>Description:
<div>Daylight: 7:00am-3:30pm
REQUIRED:
Current RN license with 3-5 years acute nursing experience
Strong knowledge of sepsis pathophysiology &amp; management
Demonstrated experience with clinical documentation review
&amp; management
Ability to apply clinical judgement to documentation, qualify
&amp; payer requirements 

PREFERRED:
CDI certification (CDIP, CCDS, CCDs-0) or willingness to obtain
Within a defined timeframe preferred
Sepsis abstraction or quality experience preferred
Experience with payer audits, denials or appeals
rushk@acmh.org</div></div>

Clinical Documentation Specialist - Sepsis Coordinator

DelRicht Research

<div>
 Why DelRicht Research?
 
 
 Would you love to be a part of the cutting edge of healthcare and science innovation? Are you looking for a position that has sustainable opportunities for professional growth? We are a clinical research company dedicated to providing an excellent customer experience to all patients that participate in our clinical trials. Our clinical trials provide new treatment options for our patients and, ultimately, our goal is to get new medications and medical devices FDA approved. We are currently looking for a detail-oriented, confident Clinical Documentation Specialist to join our team.
 
 
 DelRicht Research has been recognized as one of New Orleans Top Workplaces for 2023, 2024, and 2025! This is a testament to our unwavering commitment to creating an exceptional work environment that fosters growth, collaboration, and employee satisfaction.
 
 
 NOTE: This is an onsite M-F position based at our New Orleans Corporate Headquarters location.
 
 
 Who We Are
 
 
 DelRicht is a clinical research company dedicated to providing an excellent customer experience to all patients that participate in our clinical trials. Our clinical trials provide new treatment options for our patients and ultimately our goal is to get new medications FDA approved! We hold our team members to a high standard of excellence and are looking for energetic, positive, quick learners to be a part of our team. Presently our network stretches across 18 sites throughout the United States.
 
 
 Clinical Documentation Specialist&rsquo;s Main Objective: This role is responsible for supporting the Quality Assurance (QA) team with process improvement initiatives, as well as training, and trend identification across the site network&rsquo;s clinics. The Clinical Documentation Specialist will maintain clinical trial data integrity to ensure site is audit ready at all times
 
 
 The Clinical Documentation Specialist Will Assist With Oversight And Maintenance Of Activities Related To The Conduct Of Clinical Trials At The Site Including But Not Limited To
 
 
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 Complete Quality Assurance (QA) chart reviews, ensuring consistency, accuracy, and timeliness
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 Ensure that clinical trial protocols are being adhered to 100% of the time
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 Coordinate, communicate and collaborate with clinical teams across our site network
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 Maintain a working knowledge of FDA regulations, GCP/ICH guidelines, organizational SOPs, guidance documents and study protocols
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 Detail plans for timely correction of electronic source errors
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 Ensure both inter- and intra-site consistency in source completion
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 Manage and report charting trends to leadership
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 Assist with training for both clinical teams and the QA department
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 Assist the QA manager with internal team training, developing and disseminating reports, and management tasks related to QA Coordinators
 
 
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 The Right Candidate Will
 
 
 
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 Required: Minimum 3 years of professional work experience
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 Required: B.S or B.A from any accredited university in any degree
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 Required: Experience in a clinic, quality assurance, project management, or similar healthcare environment
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 Required: Familiarity with medical intake and terminology.
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 Required: Experience with quality assurance (does not have to be in healthcare)
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 Preferred: Experience working within cross-functional teams on process improvement initiatives
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 Preferred: Familiarity with clinical charting and clinical reports.
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 Be self motivated, energetic and positive
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 Be a team player with excellent communication skills
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 Be comfortable speaking to external and internal stakeholders and leaders
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 Ability to work autonomously with a high level of self accountability
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 Make sure client satisfaction is a primary focus and that the client is able to achieve and exceed their goals
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 Believe in high quality and have a high standard of compliance to our study protocols
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 Be remarkably organized with effective time management skills
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 Be skilled at problem solving and solution focused
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 Manage multiple tasks and clinical trials efficiently
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 Accept ownership of tasks from inception through completion and assume responsibility for personal success
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 Coffee drinkers preferred. Tea drinkers accepted.
 
 
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 DelRicht Research&rsquo;s Core Values: Production, Humility, Consistency
 
 
 
 Production
 
 
 
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 We deliver on our promises
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 We have a bias towards action: we value independent problem solving
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 We proactively over deliver: we can act without being told what to do and we always have new ideas that will be heard and will improve the company
 
 
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 Humility
 
 
 
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 We support each other relentlessly
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 We always have enthusiasm: we exhibit passion and excitement about our work which leads to everyone having a &lsquo;can do&rsquo; attitude
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 We embrace change: we are excited to always be growing and moving the organization forward which means change is the norm for us
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 Coachable: we all love to learn, we are willing to be taught and will adapt quickly
 
 
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 Consistency
 
 
 
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 We always are able to execute: we get it right the first time and promote &lsquo;touch it once&rsquo; accuracy
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 We have persistence: we demonstrate the tenacity and willingness to go the distance to get something done
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 We are calm under pressure: we can maintain stable performance when under heavy pressure or stress
 
 
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 Our team comes first so here are some of the perks and benefits at DelRicht Research:
 
 
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 Comprehensive benefits - medical, dental &amp; vision
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 Generous Paid Time Off that builds throughout your career with the company
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 Even though we are in healthcare, we do not work nights, weekends or long day shifts (yes nurses love us)
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 401K (including discretionary match/profit sharing)
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 Exceptional quarterly bonus plan that clearly outlines your bonus potential per quarter and giving the team the visibility and control to maximize earnings by hitting team goals
 
 
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 Visit our website linked below to learn about our company and current clinical trials, see patient testimonials, and check out our careers page!
 
 
 Website: www.delrichtresearch.com
 
 
 Patient Testimonials: https://delrichtresearch.com/testimonials/
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