clinical documentation improvement specialist

Valley Medical Center

<div></div><div><div><div><ul><li><h6 class="jobSectionHeader"><b>Job Title:</b></h6>
 Clinical Documentation Specialist
</li><li><h6 class="jobSectionHeader"><b>Req:</b></h6>
 2026-0293
</li><li><h6 class="jobSectionHeader"><b>Location:</b></h6>
 VMC Main Campus
</li><li><h6 class="jobSectionHeader"><b>Department:</b></h6>
 Health Information Mgmt
</li><li><h6 class="jobSectionHeader"><b>Shift:</b></h6>
 Days
</li><li><h6 class="jobSectionHeader"><b>Type:</b></h6>
 Full Time
</li><li><h6 class="jobSectionHeader"><b>FTE:</b></h6>
 1
</li><li><h6 class="jobSectionHeader"><b>Hours:</b></h6>
</li><li><h6 class="jobSectionHeader"><b>City State:</b></h6>
 Renton, WA
</li><li><h6 class="jobSectionHeader"><b>Salary Range:</b></h6>
 Min $94,894 - Max $142,341/annual DOE</li></ul></div></div><br>
<br>
<br>
<br>
<p></p><p><b>Job Description:</b></p>
<p>VALLEY MEDICAL CENTER</p>
<p>
</p><p><b>JOB DESCRIPTION</b></p>
<p>
</p><p>The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.</p>
<p>
</p><p><b>TITLE:</b> Clinical Documentation Specialist RN</p>
<p>
</p><p><b>JOB OVERVIEW:</b> The Clinical Documentation Specialist position facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the documentation improvement process is a key role.</p>
<p>
</p><p><b>DEPARTMENT:</b> Health Information Management</p>
<p>
</p><p><b>HOURS OF</b> <b>WORK:</b> Days Monday - Friday.</p>
<p>
</p><p><b>RESPONSIBLE TO:</b> Manager, Clinical Documentation Improvement</p>
<p>
</p><p>PREREQUISITES:</p>
<div>
<ul><li><p>Current unrestricted WA State Registered Nurse license, required.</p>
</li></ul>
<ul><li><p>Bachelor's degree in Nursing, preferred.</p>
</li></ul>
<ul><li><p>Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review</p>
</li></ul>
<ul><li><p>Pass a pre-hire Clinical Exam with a minimum score of 70%</p>
</li></ul>
<ul><li><p>Effective communication with Providers</p>
</li></ul>
</div><p></p><p>QUALIFICATIONS:</p>
<div>
<ul><li><p>Knowledge of hospital clinical practice standards for physicians and other health care providers.</p>
</li></ul>
<ul><li><p>Knowledge of ancillary service departments, quality control and safety standards.</p>
</li></ul>
<ul><li><p>Critical thinking, problem solving and deductive reasoning skills.</p>
</li></ul>
<ul><li><p>Familiarity with health care audit and research design.</p>
</li></ul>
<ul><li><p>Knowledge of Pathophysiology and Disease process.</p>
</li></ul>
<ul><li><p>Functional knowledge of DRG coding systems.</p>
</li></ul>
<ul><li><p>Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.</p>
</li></ul>
<ul><li><p>Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.</p>
</li></ul>
<ul><li><p>Meet productivity guidelines.</p>
</li></ul>
<ul><li><p>Ability to learn/develop the skills necessary to perform and meet goal standards</p>
</li></ul>
<ul><li><p>Organizational, analytical, writing, and interpersonal skills</p>
</li></ul>
<ul><li><p>Dependable, self-directed, and pleasant</p>
</li></ul>
<ul><li><p>Critical thinking, problem solving and deductive reasoning skills</p>
</li></ul>
<ul><li><p>Knowledge of Pathophysiology and Disease Process</p>
</li></ul>
<ul><li><p>Basic Computer skills - familiarity with Windows based software programs</p>
</li></ul>
<ul><li><p>Knowledge of regulatory environment</p>
</li></ul>
<ul><li><p>Understand and support documentation strategies (upon completion of training)</p>
</li></ul>
<ul><li><p>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)</p>
</li></ul>
</div><p></p><p>UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT AND WORKING CONDITIONS:</p>
<p>
See Generic Job Description for Administrative Partner.</p>
<p>
</p><p>PERFORMANCE RESPONSIBILITIES:</p>
<p>
A. Generic Job Functions: <i>See Generic Job Description for Administrative Partner.</i></p>
<p>
B. Essential Responsibilities and Competencies</p>
<div>
<ul><li><p>Reviews EMR for completeness and accuracy for severity of illness and quality using the documentation strategies.</p>
</li></ul>
<ul><li><p>Accurate and timely record review.</p>
</li></ul>
<ul><li><p>Recognize opportunities for documentation improvement.</p>
</li></ul>
<ul><li><p>Initiates severity worksheet for inpatients.</p>
</li></ul>
<ul><li><p>Formulate clinically credible documentation clarifications.</p>
</li></ul>
<ul><li><p>Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety.</p>
</li></ul>
<ul><li><p>Effective and appropriate communication with physicians.</p>
</li></ul>
<ul><li><p>Timely follow up on all cases and resolution of those with clinical documentation clarifications.</p>
</li></ul>
<ul><li><p>Communicates with HIM staff and resolves discrepancies.</p>
</li></ul>
<ul><li><p>Accurate input of data for reconciliation of case.</p>
</li></ul>
<ul><li><p>Provide necessary information and education to physicians and staff to facilitate the appropriate documentation goals.</p>
</li></ul>
<ul><li><p>Identify any barriers to completion of documentation goals with appropriate interventions.</p>
</li></ul>
<ul><li><p>Review of regulations and coding guidelines through seminars, meetings, and materials.</p>
</li></ul>
<ul><li><p>In cooperation with the director of PFS/HIM, present education sessions to physicians and other VMC providers regarding documentation regulations and chart audit findings.</p>
</li></ul>
<ul><li><p>Maintains confidentiality of all accessible patient financial or medical records information.</p>
</li></ul>
<ul><li><p>Demonstrates the awareness of the importance of cost containment for the department. Provide suggestions regarding process or quality improvement opportunities to department manager.</p>
</li></ul>
<ul><li><p>Other duties as assigned to facilitate accurate, timely patient account management.</p>
</li></ul>
</div><p></p><p>Date Created: 5/18, updated 7/22</p>
<p>
Grade: NC11</p>
<p>
FLSA: E</p>
<p>
Cost Center: 8490</p><br>
<p><b>
Job Qualifications:</b></p>
<p>PREREQUISITES:</p>
<div>
<ul><li><p>Current unrestricted WA State Registered Nurse license, required.</p>
</li></ul>
<ul><li><p>Bachelor's degree in Nursing, preferred.</p>
</li></ul>
<ul><li><p>Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review</p>
</li></ul>
<ul><li><p>Pass a pre-hire Clinical Exam with a minimum score of 70%</p>
</li></ul>
<ul><li><p>Effective communication with Providers</p>
</li></ul>
</div><p></p><p>QUALIFICATIONS:</p>
<div>
<ul><li><p>Knowledge of hospital clinical practice standards for physicians and other health care providers.</p>
</li></ul>
<ul><li><p>Knowledge of ancillary service departments, quality control and safety standards.</p>
</li></ul>
<ul><li><p>Critical thinking, problem solving and deductive reasoning skills.</p>
</li></ul>
<ul><li><p>Familiarity with health care audit and research design.</p>
</li></ul>
<ul><li><p>Knowledge of Pathophysiology and Disease process.</p>
</li></ul>
<ul><li><p>Functional knowledge of DRG coding systems.</p>
</li></ul>
<ul><li><p>Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.</p>
</li></ul>
<ul><li><p>Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.</p>
</li></ul>
<ul><li><p>Meet productivity guidelines.</p>
</li></ul>
<ul><li><p>Ability to learn/develop the skills necessary to perform and meet goal standards</p>
</li></ul>
<ul><li><p>Organizational, analytical, writing, and interpersonal skills</p>
</li></ul>
<ul><li><p>Dependable, self-directed, and pleasant</p>
</li></ul>
<ul><li><p>Critical thinking, problem solving and deductive reasoning skills</p>
</li></ul>
<ul><li><p>Knowledge of Pathophysiology and Disease Process</p>
</li></ul>
<ul><li><p>Basic Computer skills - familiarity with Windows based software programs</p>
</li></ul>
<ul><li><p>Knowledge of regulatory environment</p>
</li></ul>
<ul><li><p>Understand and support documentation strategies (upon completion of training)</p>
</li></ul>
<ul><li><p>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)</p></li></ul></div></div><p></p>

Clinical Documentation Specialist

Ascension

<div>We Are Hiring:
<div><b>
Location: </b>Remote</div><div><b>
Facility: </b>Ascension Wisconsin Hospitals</div><div><b>
Department/Specialty: </b>Clinical Integrity Documentation</div><div><b>
Schedule: </b>Days | Full Time</div><div><b>
Salary Range:</b> $79,511.52-$110,834.59</div>
What You Will Do:
<div>
Facilitate improvement in overall quality, completeness and accuracy of medical record documentation.</div><ul><li>
Complete admission reviews and assign a working Diagnosis Related Group. Ensure the working DRG and other information are entered in the Clinical Documentation Improvement database.</li><li>
Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.</li><li>
Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge.</li><li>
Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.</li></ul>
What You Will Need:
<div>
Licensure / Certification / Registration:</div><ul><li>
One or more of the following required:<ul><li>
Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.</li><li>
Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.</li><li>
Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.</li><li>
Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.</li><li>
Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.</li><li>
Licensed Registered Nurse credentialed from the Wisconsin Board of Nursing or current home state license for multi-state license recognition &quot;Compact State&quot; obtained prior to hire date or job transfer date.</li></ul></li></ul><div>
Education:</div><ul><li>
High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.</li></ul>
Additional Preferences:
<ul><li>5 or more years of nursing experience in ICU and/or Emergency Department</li><li>
Previous Clinical Documentation Specialist experience</li></ul>
Why Join Our Team:
<div>
Ascension is a leading nonprofit Catholic health system with a culture and associate experience grounded in service, growth, care and connection. We empower our 99,000+ associates to bring their skills and expertise every day to reimagining healthcare, together. Recognized as one of the Best 150+ Places to Work in Healthcare and a Military-Friendly Gold Employer, you&rsquo;ll find an inclusive and supportive environment where your contributions truly matter.</div>
Equal Employment Opportunity Employer:
<p><b><i>
Equal employment opportunity employer
</i></b></p><p>Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws. For further information, view the EEO Know Your Rights (English) poster or EEO Know Your Rights (Spanish) poster.</p><p><b><i>
Fraud prevention notice
</i></b></p><p>Prospective applicants should be vigilant against fraudulent job offers and interview requests. Scammers may use sophisticated tactics to impersonate Ascension employees. To ensure your safety, please remember: Ascension will never ask for payment or to provide banking or financial information as part of the job application or hiring process. Our legitimate email communications will always come from an @ascension.org email address; do not trust other domains, and an official offer will only be extended to candidates who have completed a job application through our authorized applicant tracking system.</p><p><b><i>
E-Verify statement</i></b></p><div>
Employer does not participate in E-Verify and therefore cannot employ STEM OPT candidates.</div>
Benefits:
<div>
Paid time off (PTO)<br>
Various health insurance options &amp; wellness plans<br>
Retirement benefits including employer match plans<br>
Long-term &amp; short-term disability<br>
Employee assistance programs (EAP)<br>
Parental leave &amp; adoption assistance<br>
Tuition reimbursement<br>
Ways to give back to your community</div><div></div><div><i><br>
Benefit options and eligibility vary by position. Compensation varies based on factors including, but not limited to, experience, skills, education, performance, location and salary range at the time of the offer.</i></div></div>

White Oak Management, Inc.

<p><b>Overview</b><br/>Join our dynamic healthcare team as an Assistant Director of Nursing / MDS Coordinator, where you will play a pivotal role in ensuring exceptional patient care and compliance with regulatory standards. This energetic position offers the opportunity to lead clinical documentation improvement initiatives, coordinate comprehensive assessments, and oversee medical records management within a fast-paced, multidisciplinary environment. Your expertise will directly impact patient outcomes, operational efficiency, and adherence to industry standards such as NCQA and HIPAA. If you thrive in a collaborative setting and possess a passion for nursing excellence and healthcare management, this role is your next career milestone!</p><p><b>Duties</b></p><ul><li>This is an on-call role features an on-call rotation schedule.</li><li>Lead the development and implementation of the Minimum Data Set (MDS) assessments to ensure accurate and timely completion in compliance with federal regulations.</li><li>Coordinate interdisciplinary team efforts to optimize patient care planning, discharge planning, and clinical documentation improvement.</li><li>Oversee medical records management, ensuring accuracy, completeness, and confidentiality in accordance with HIPAA standards.</li><li>Utilize advanced EMR (Electronic Medical Record) systems such as Ecin, Epic, or PCC to review medical documentation, coding, and clinical data.</li><li>Conduct utilization review and utilization management activities to support appropriate resource allocation and reimbursement processes including Medicare and managed care programs.</li><li>Collaborate with nursing staff on CPT coding, ICD-9/10 coding, DRG assignment, and medical documentation review to enhance coding accuracy and reimbursement.</li><li>Facilitate training sessions on healthcare regulations, ICD coding updates, and documentation best practices for clinical staff.</li><li>Assist in case management activities like discharge planning for hospice care or outpatient services to ensure seamless patient transitions across care settings.</li></ul><p><b>Experience</b></p><ul><li>Proven experience in nursing leadership roles with a focus on MDS coordination or clinical documentation improvement within long-term care facilities or hospitals.</li><li>Extensive knowledge of Epic EMR systems used for medical records management.</li><li>Demonstrated expertise in ICD-10/ICD-9 coding, CPT coding, DRG assignment, and Medicare regulations related to inpatient and outpatient billing processes.</li><li>Strong background in managed care environments with familiarity in utilization review and utilization management processes.</li><li>Critical care experience preferred along with nursing home experience or hospital-based acute care exposure.</li><li>Familiarity with healthcare quality standards such as NCQA standards; experience supporting clinical documentation improvement initiatives is highly desirable.</li><li>Knowledge of physiology, anatomy, medical terminology, HIPAA compliance requirements, and health information management practices essential for success.</li><li>Excellent communication skills combined with the ability to train multidisciplinary teams on complex documentation procedures while maintaining a lively enthusiasm for continuous improvement. Embark on a rewarding career journey where your leadership enhances patient outcomes through meticulous documentation and innovative healthcare solutions!</li></ul><p>Pay: Up to $45.00 per hour</p><p>Benefits:</p><ul><li>Dental insurance</li><li>Health insurance</li><li>Paid time off</li><li>Vision insurance</li></ul><p>Work Location: In person</p>

Assistant Director of Nursing / MDS Coordinator

Trinity Health

<div>
 <strong>
  Employment Type
  <br/>
  <br/>
 </strong>
 Full time
 <br/>
 <br/>
 <strong>
  Shift
  <br/>
  <br/>
 </strong>
 Day Shift
 <br/>
 <br/>
 <strong>
  Description
  <br/>
  <br/>
 </strong>
 This is a M-F, 8a-5p remote position that requires certification. For the Holy Cross Medical Group this individual performs charge entry, charge approvals, and/or quality charge reviews; including but not limited to, appending modifiers and checking clinical documentation. Works closely with Revenue Integrity staff and providers to educate on improved documentation to support coding. Neurosurgery experience is highly preferred. CPC license is REQUIRED.
 <br/>
 <br/>
 <strong>
  What You Will Do
  <br/>
  <br/>
 </strong>
 Responsible for coding and/or validation of charges for more complex service lines, advanced proficiencies in surgical or specialty coding practice.
 <br/>
 <br/>
 Review chart, including nursing notes, physician orders, progress notes, and surgical or specialty notes thoroughly to interpret and validate and/or extract all charges. Ensure each chart is complete according to specified guidelines. Ensure charges captured on the correct patient, correct encounter, correct date of service, with any required modifiers.
 <br/>
 <br/>
 Review documentation, abstracts data and ensure charges/coding are in alignment within AMA and Medicare coding guidelines. Ensure medical documentation and coding compliance with Federal, State and Private payer regulations. a. Perform coding functions, including CPT, ICD-10 assignment, documentation review and claim denial review b. Responsible for proofing daily charges for accuracy and clean claim submission c. Responsible for balancing charges and adjustments d. Maintain productivity standards e. Maintain compliance with regulatory requirements
 <br/>
 <br/>
 Responsible for denial coordination with Patient Business Service (PBS) centers, including analysis of clinical documentation, assisting in appeals, root cause analysis and tracking as needed. 6. Educates clinical staff on need for accurate and complete documentation to ensure revenue optimization and integrity.
 <br/>
 <br/>
 Educate clinical staff on need for accurate and complete documentation to ensure revenue optimization and integrity.
 <br/>
 <br/>
 Perform outpatient clinical documentation improvement review (acute only) as needed.
 <br/>
 <br/>
 Perform research on charges and communicate findings to intra and inter-departmental colleagues.
 <br/>
 <br/>
 Maintain a minimum productivity standard, based on service line and charge type; including but not limited to, chart review, charge extraction, E&amp;M level assignment and charge entry.
 <br/>
 <br/>
 <strong>
  Minimum Qualifications
  <br/>
  <br/>
 </strong>
 Other related responsibilities as assigned by manager.
 <br/>
 <br/>
 <ul>
  <li>
   High school diploma or equivalent combination of education and experience.
  </li>
  <li>
   Minimum three (3) years of relevant coding and charge control work experience in a Hospital and/or Physician Practice environment and experience in revenue cycle, billing, coding and/or patient financial services.
  </li>
  <li>
   Strong working knowledge of medical terminology, data entry, supply chain processes, hospital and/or Medical Group practice operations.
  </li>
  <li>
   Licensure / Certification: CPC license required.
  </li>
  <li>
   Neurosurgery experience preferred
  </li>
  <li>
   Must possess a demonstrated knowledge of clinical processes, clinical coding (CPT, HCPCS, ICD-9/10, revenue codes and modifiers), charging processes and audits, and clinical billing. Strong understanding of various medical claim formats.
  </li>
  <li>
   Knowledge of clinical documentation improvement processes strongly preferred.
  </li>
  <li>
   Strong knowledge of Ambulatory Payment Classification (APC), and Outpatient Prospective Payment System (OPPS) reimbursement structures and pre-bill edits including Outpatient Coding Edits (OCE)/Correct Coding Initiative (CCI) edits and Discharged Note Final Billed (DNFB).
  </li>
  <li>
   Ability to perform charge capture processes, including understanding technical integration of electronic medical record and the automation of charge triggers, and ability to investigate charge errors accordingly. Epic experience desired.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Position Highlights And Benefits
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Comprehensive benefit packages available, including medical, dental, vision, paid time off, 403B, and education assistance.
  </li>
  <li>
   Comprehensive benefits that start on your first day of work
  </li>
  <li>
   Retirement savings program with employer matching
  </li>
  <li>
   We serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.
  </li>
  <li>
   We live and breathe our guiding behaviors: we support each other in serving, we communicate openly, honestly, respectfully, and directly, we are fully present, we are all accountable, we trust and assume goodness in intentions, and we are continuous learners.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Ministry/Facility Information
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   A member of Trinity Health, one of the largest multi-institutional Catholic health care delivery systems in the nation, Fort Lauderdale-based Holy Cross Hospital, dba Holy Cross Health, is a full-service, not-for-profit, Catholic, teaching hospital operating in the spirit of the Sisters of Mercy.
  </li>
  <li>
   We are the only not-for-profit Catholic hospital in Broward and Palm Beach counties.
  </li>
  <li>
   Through strategic collaborations and a commitment to being a person-centered, transforming, healing presence, the 557-bed hospital offers progressive inpatient, outpatient and community outreach services and clinical research trials to serve as our community&rsquo;s trusted health partner for life. We are committed to providing compassionate and holistic person-centered care.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Legal Info
  <br/>
  <br/>
 </strong>
 We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.
 <br/>
 <br/>
 <strong>
  Our Commitment
  <br/>
  <br/>
 </strong>
 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>


Coding Specialist - CPC Required

Rochester Regional Health

<div><p><b>SUMMARY</b></p><p>
The CDS facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care and quality in the medical record. This involves extensive record review and interaction with members of the healthcare team and ancillary teams.</p><p></p><p><b>
STATUS: Full-time</b></p><p><b>
LOCATION: Remote</b></p><p><b>
DEPARTMENT: Clinical Documentation
</b></p><p><b>SCHEDULE: Day shift</b></p><p></p><p><b>
ATTRIBUTES</b></p><ul><li>Ability to learn/develop the skills necessary to perform the CDS role</li><li>Organizational, analytical, writing and interpersonal skills</li><li>Dependable, self-directed and pleasant</li><li>Critical thinking, problem solving and deductive reasoning skills</li><li>Knowledge of Pathophysiology and Disease Process</li><li>Basic Computer skills &ndash; familiarity with Windows based software programs</li><li>Knowledge of regulatory environment</li><li>Understand and support CDS documentation strategies (upon completion of training)</li><li>Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (upon completion of training)</li><li>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)</li><li>For Skilled Nursing Facility Only:</li></ul>
a. Understand Medicare Part A guidelines<br>
b. Understand the current FY SNF PPS Final Rule<br>
c. Understand the CMS Clinical Category Crosswalk tool for PDPM ICD-10-CM Mappings<br>
d. Understand the MDS Resident Assessment Instrument (RAI) Manual<br>
e. Ability to use the CMS PDPM Calculator Tool<div><br>
Minimum Qualifications:<br>
<ul><li>3-5 years of adult acute care experience in med/surg., critical care, emergency room, or PACU.</li><li>Registered nursing degree required, BSN preferred. Other clinical education may be considered, such as PA, NP, or MD.</li><li>Previous CDS experience preferred</li></ul></div><ul><li>For Skilled Nursing Facility Only:</li></ul>
a. 3 years of patient care, or CDI or Coding experience in an adult population, acute care or skilled nursing facility<br>
b. Registered Nursing Degree required, BSN preferred, or other clinical education may be considered such as LPN, PA, NP, or MD.<br>
OR a degree in Health Information Management (Associate&rsquo;s Degree with RHIT; Bachelor&rsquo;s Degree with RHIA)<p><br>
Required Licensure/Certification:<br>
RN, PA, NP, MBBS or MD prepared candidates.<br>
If hired after January 1, 2017: Must obtain CCDS certification within 30 months of hire.</p><p>
For Skilled Nursing Facility Only:<br>
Valid RN or LPN license, or other applicable professional license, or RHIT, or RHIA</p><p>
Rochester General Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran</p><p></p><p><b>
RESPONSIBILITIES</b></p><ul><li><ul><li>Reviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality</li><li>Accurate and timely record review</li><li>Recognize opportunities for documentation improvement</li><li>Formulate clinically credible documentation clarifications</li><li>Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety</li><li>Effective and appropriate communication with physicians</li><li>Provides education to members of the patient care team regarding the CDS process.</li><li>Timely follow up on all cases and resolution of those with clinical documentation clarifications</li><li>Actively participate in Team Meetings</li><li>Manage multiple priorities</li><li>Communicates with HIM staff and resolves discrepancies</li><li>Accurate input of data into department software</li><li>For Skilled Nursing Facility Only:</li></ul>
a. Utilize the ICD-10-CM Official Guidelines for Coding &amp; Reporting and their application in the long-term healthcare setting.<br>
b. Utilize an ICD-10-CM indexing system to determine appropriate ICD-10-CM codes.<br>
c. Collaborate with the hospital and skilled nursing facility (SNF) team members to ensure documentation supports the most specified, appropriate, and billable ICD-10-CM code(s) for primary and secondary diagnoses (co-morbidities) to be assigned for a SNF authorization, and PPS assessments required under PDPM.</li></ul><p></p><p>
#RRHProfessional26</p><p></p><p><b>
EDUCATION:</b></p><p></p><p><b>
LICENSES / </b><b>CERTIFICATIONS:</b></p>
RN - Registered Nurse - New York State Education Department (NYSED)<p></p><p><b>
PHYSICAL REQUIREMENTS:</b></p>
S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.<p></p><p><b>
For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.</b><b>
</b></p><p></p><p><b>Any physical requirements reported by a prospective employee and/or employee&rsquo;s physician or delegate will be considered for accommodations.
</b></p><p></p><p><b>PAY RANGE:</b></p>
$78,000.00 - $95,000.00<p></p><div><div><div><div><div><div><div><p><b>
CITY:</b></p></div></div></div></div></div></div></div>
Rochester<p></p><div><div><div><div><div><div><div><p><b>
POSTAL CODE:</b></p></div></div></div></div></div></div></div>
14621<p></p><p><b><i>
The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.</i></b></p><p></p><p><b>
Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.</b></p></div>

North Memorial Health

<div></div><div><div><div><div><div><div><p>Requisition Number: 513291</p>
</div>
</div><br>
</div></div><div><div><div><div><p><b>Why North Memorial Health?
</b></p><p>At North Memorial Health, you&rsquo;re part of an inclusive health team that is rooted in our values: Advocate Courageously, Rally Together, Respect Uniqueness and Create Impact. Empathy and care are at the heart of North&rsquo;s culture which is designed to actively support each team member&rsquo;s wellbeing and growth. Our strength lies in our diversity, and we embrace the unique contributions and experiences of each person. Together, we empower patients to achieve their best health.</p>
<p>
Our health system encompasses two hospital locations in Robbinsdale and Maple Grove as well as a network of 23 clinics which includes 13 primary clinics, 6 specialty clinics, 4 urgent care/urgency centers and emergency care offerings covering five counties. Our Robbinsdale Hospital, established in 1954, is a 385-bed facility recognized as the top Level 1 Trauma center for 25 years, as well as serving as a Level II pediatric trauma center. Our Maple Grove Hospital was established in 2009, is a 134-bed facility recognized as a top hospital in the state for Women and Children Care, with a Level III NICU, and is the largest Family Birth Center in the state (~5,000 deliveries per year and over 60,000 babies delivered). Both have been named to the 2022 Fortune/Merative 100 Top Hospitals&reg; list, 2023 Women&rsquo;s Choice Award Best Hospitals list.</p>
<p><b>
Benefits the North Way!</b></p>
<p>
As North Memorial Health is a non-profit organization you are eligible for the Public Student Loan Forgiveness program. Most part-time and all full-time positions are eligible for benefits.</p>
<ul>
<li>Health &amp; Welfare Benefit Packages</li>
<li>401k Retirement Match or Pension Plan, based on workgroup eligibility</li>
<li>Generous Paid Time Off (PTO) Plans</li>
<li>Adoption Reimbursement up to $3000 per child</li>
<li>Child Care Discount Program with New Horizon 10% off weekly childcare tuition</li>
<li>Education/Tuition Reimbursement</li>
<li>24/7 Fitness Center Access for all benefit eligible team members</li>
</ul>
<p><b>Commitment to Diversity, Equity &amp; Inclusion</b></p>
<p>
At North Memorial Health we recognize that the strength of our team lies in our diversity and make every effort to embrace the unique contributions and experiences of each person on our team. We strive to ensure that everyone feels like they are a valuable part of our community, with initiatives that reinforce our belief in diversity, equity, and inclusivity, to promote a workforce that enables authenticity, as we want to be our best when providing effective services to our patients. We acknowledge and celebrate the unique traditions, backgrounds, languages, beliefs, and customs of our community, and want everyone to feel welcome. Through our DE&amp;I initiatives we hope to dispel myths, assumptions, and acts of implicit bias.</p>
<p><b>
About this position</b></p>
<p>
The Clinical Improvement Specialist performs clinical care coordination and oversight to ensure patient care staff is delivering highest level of appropriate patient care.</p><br>
<p></p>
<p><b>
Requirements</b></p>
<p><b>
Education</b></p>
<div><ul><li>Graduate from an accredited school of nursing</li><li>Associate's degree in nursing and 2 years of nursing experience or bachelor's degree in nursing required</li></ul><br>
</div><p><b>Experience</b></p>
<div><ul><li>1-2 years nursing experience required; 3+ preferred.</li><li>Previous leadership preferred.
</li></ul><br>
Knowledge, Skills and Abilities<br>
<ul><li>Knowledge of nursing theory and practice.
</li><li>Ability to maintain quality, safety, and infection control standards.
</li><li>Knowledge of Primary Care Principles/Practices.
</li><li>Strong computer skills.</li></ul><br>
</div><p><b>Licensure/Certification</b></p>
<div><ul><li>Current licensure as RN in State of Minnesota</li><li>State Requirement</li><li>Current American Heart Association BLS
</li><li>certification or completion of training and certification during first 30 days of</li></ul>
employment<br>
<ul><li>NMHC Standard</li></ul></div><p><b><i><br>
The North Memorial Health System is dedicated to building a diverse, inclusive, and authentic workplace, so if you&rsquo;re excited about this role, but your past experience doesn&rsquo;t perfectly align with every qualification listed, we encourage you to apply anyway. You may still be the right candidate for this or other roles.</i></b></p></div><div><br>
<p>
Work Group: Non Contract</p>
<p>
Hours per two week pay period: 80</p>
<p>
Shift: Days 8 hours
</p><p>Weekend Requirement: None</p>
<p>
Call Requirement: None</p>
<p>
Remote or On-site: On-site</p>
<p>
FLSA Status: Exempt</p>
<p>
Benefit Eligibility: Health insurance benefits are available for this position. North Memorial Health offers multiple health plans based on work group eligibility.</p>
<p>
Salary Range: B24 ($42.29-$63.44), based on experience
</p><p>Shift Differential: Compensation may include shift differential pay depending on the position and shift worked.</p>
<p>
Employment Sponsorship: Applicants must be currently authorized to work in the United States on a full-time basis. Work visa sponsorship is not available for this position</p></div></div></div></div></div></div>

Clinical Improvement Specialist - Multiple Locations

Northwell Health

<div><p>Job Description</p><p>
Participates in interdisciplinary and process improvement teams to identify potential future uses of the information systems and potential improvements in the current use of the systems. Serves as a nursing informatics resource, to individuals and teams within Patient Care Services.</p><p>
Job Responsibility</p><p>
</p><ul><li>Knowledgeable of Performance Improvement methodology used within the organization.</li><li>
Maintains up-to-date knowledge of trends and advances in Nursing Informatics, as well as new developments in hardware and software technology; uses this knowledge in supporting users and process teams.</li><li>
Participates in preparation of Performance Improvement reports for care services presentation at committee meeting; reports to Hospital Quality Management for external benchmarking as needed.</li><li>
Assists in conducting focus studies to measure and assess patient care services&rsquo; process stability and the achievement of patient outcomes and organizational goals.</li><li>
Assists in coordinating investigations of state reportable incidents/complaints, sentinel events, citations and data collection for corrective actions.</li><li>
Participates in special projects related to quality issues; assists in recommendations and coordinating implementation of plan of corrective action; assists in preparing monthly variance reports for the leadership, physicians, and other hospital personnel as needed Presents patient specific issues and other concerns to appropriate leadership and Performance Improvement Committees for resolution of conflicts.</li><li>
Uses office technology and data base systems to perform functions of the job; creates documents for formal presentations and storyboards.</li><li>
Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.</li></ul><p>
Job Qualification</p><p>
</p><ul><li>BSN nursing degree, required. Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed</li><li>
Current license to practice as a Registered Professional Nurse OR as a Nurse Practitioner in New York State OR current Licensed Registered Physician Assistant by New York State Department of Education, required.
</li><li>One-three (1-3) years clinical experience including general knowledge of QM principles, NYPORTS and JCAHO requirements.</li><li>
Peri Op experience, preferred.</li></ul><div><ul><li><br>
<b>Additional Salary Detail</b>
</li></ul>The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).</div></div>

Clinical Quality Improvement Specialist

Search 9490+ Clinical documentation improvement specialist jobs near you this June. New roles added regularly across leading industries. Apply today.

9490 clinical documentation improvement specialist jobs Near Me

Clinical Documentation Specialist

Clinical Documentation Specialist

Assistant Director of Nursing / MDS Coordinator

Coding Specialist - CPC Required

Clinical Documentation Specialist

Clinical Improvement Specialist - Multiple Locations

Clinical Quality Improvement Specialist