clinical documentation manager

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

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
 
 
 <ul>
 <li>
 Complete Quality Assurance (QA) chart reviews, ensuring consistency, accuracy, and timeliness
 </li>
 <li>
 Ensure that clinical trial protocols are being adhered to 100% of the time
 </li>
 <li>
 Coordinate, communicate and collaborate with clinical teams across our site network
 </li>
 <li>
 Maintain a working knowledge of FDA regulations, GCP/ICH guidelines, organizational SOPs, guidance documents and study protocols
 </li>
 <li>
 Detail plans for timely correction of electronic source errors
 </li>
 <li>
 Ensure both inter- and intra-site consistency in source completion
 </li>
 <li>
 Manage and report charting trends to leadership
 </li>
 <li>
 Assist with training for both clinical teams and the QA department
 </li>
 <li>
 Assist the QA manager with internal team training, developing and disseminating reports, and management tasks related to QA Coordinators
 
 
 </li>
 </ul>
 
 The Right Candidate Will
 
 
 
 <ul>
 <li>
 Required: Minimum 3 years of professional work experience
 </li>
 <li>
 Required: B.S or B.A from any accredited university in any degree
 </li>
 <li>
 Required: Experience in a clinic, quality assurance, project management, or similar healthcare environment
 </li>
 <li>
 Required: Familiarity with medical intake and terminology.
 </li>
 <li>
 Required: Experience with quality assurance (does not have to be in healthcare)
 </li>
 <li>
 Preferred: Experience working within cross-functional teams on process improvement initiatives
 </li>
 <li>
 Preferred: Familiarity with clinical charting and clinical reports.
 </li>
 <li>
 Be self motivated, energetic and positive
 </li>
 <li>
 Be a team player with excellent communication skills
 </li>
 <li>
 Be comfortable speaking to external and internal stakeholders and leaders
 </li>
 <li>
 Ability to work autonomously with a high level of self accountability
 </li>
 <li>
 Make sure client satisfaction is a primary focus and that the client is able to achieve and exceed their goals
 </li>
 <li>
 Believe in high quality and have a high standard of compliance to our study protocols
 </li>
 <li>
 Be remarkably organized with effective time management skills
 </li>
 <li>
 Be skilled at problem solving and solution focused
 </li>
 <li>
 Manage multiple tasks and clinical trials efficiently
 </li>
 <li>
 Accept ownership of tasks from inception through completion and assume responsibility for personal success
 </li>
 <li>
 Coffee drinkers preferred. Tea drinkers accepted.
 
 
 </li>
 </ul>
 DelRicht Research&rsquo;s Core Values: Production, Humility, Consistency
 
 
 
 Production
 
 
 
 <ul>
 <li>
 We deliver on our promises
 </li>
 <li>
 We have a bias towards action: we value independent problem solving
 </li>
 <li>
 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
 
 
 </li>
 </ul>
 
 Humility
 
 
 
 <ul>
 <li>
 We support each other relentlessly
 </li>
 <li>
 We always have enthusiasm: we exhibit passion and excitement about our work which leads to everyone having a &lsquo;can do&rsquo; attitude
 </li>
 <li>
 We embrace change: we are excited to always be growing and moving the organization forward which means change is the norm for us
 </li>
 <li>
 Coachable: we all love to learn, we are willing to be taught and will adapt quickly
 
 
 </li>
 </ul>
 
 Consistency
 
 
 
 <ul>
 <li>
 We always are able to execute: we get it right the first time and promote &lsquo;touch it once&rsquo; accuracy
 </li>
 <li>
 We have persistence: we demonstrate the tenacity and willingness to go the distance to get something done
 </li>
 <li>
 We are calm under pressure: we can maintain stable performance when under heavy pressure or stress
 
 
 </li>
 </ul>
 Our team comes first so here are some of the perks and benefits at DelRicht Research:
 
 
 <ul>
 <li>
 Comprehensive benefits - medical, dental &amp; vision
 </li>
 <li>
 Generous Paid Time Off that builds throughout your career with the company
 </li>
 <li>
 Even though we are in healthcare, we do not work nights, weekends or long day shifts (yes nurses love us)
 </li>
 <li>
 401K (including discretionary match/profit sharing)
 </li>
 <li>
 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
 
 
 </li>
 </ul>
 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/
</div>

Providence at Home with Compassus

<div>
 
 Company
 
 
 
 Providence at Home with Compassus
 
 
 *Active California RN license required. *
 
 
 
 Location:
 
 
 This is a remote position. Work schedule M- F 8am to 5pm PST. With a rotating schedule weekend and holidays.
 
 
 
 
 Position Summary
 
 
 
 The Clinical Documentation Specialist is responsible for the quality review of all OASIS documents and review of key elements of the Plan of Care to ensure CMS program compliance is met. The Clinical Documentation Specialist works closely with the Manager of Quality Improvement and Home Health leadership to promote regulatory compliance and excellent patient outcomes and reimbursement. The Clinical Documentation Specialist serves as a role model and OASIS expert to Home Health staff across the region.
 
 
 
 Position Specific Responsibilities
 
 
 
 <ul>
 <li>
 Works in a virtual team environment in a manner that promotes team cohesiveness, efficiency, and productivity.
 </li>
 <li>
 Responsible for the timely review and processing of Start of Care, Resumption of Care, Recertification, and Significant change in Condition Home Health OASIS Assessment documents and key elements of the Plan of Care.
 </li>
 <li>
 Collaborates with leadership to analyze performance trends in OASIS accuracy; assists in determining learning needs for clinical staff.
 </li>
 <li>
 Educates and provides feedback to clinical staff in regard to correct completion of OASIS documents.
 </li>
 <li>
 Reviews of all OASIS data items and ensures accuracy of OASIS based outcome measures to reflect accurate Home Health Quality of Care Star rating and Value Based Purchasing OASIS Based component of TPS.
 </li>
 <li>
 Ensures Regulatory compliance with all OASIS conventions.
 </li>
 <li>
 Ensures timely processing of all OASIS documents to meet CMS guidelines and CMS billing requirements.
 
 
 </li>
 </ul>
 
 Education And/or Experience
 
 
 
 <ul>
 <li>
 Required - Ability to align work schedule with Pacific Time Zone business hours.
 </li>
 <li>
 Required - Education to meet certification, license or registration requirement.
 </li>
 <li>
 Required - 2 years Clinical Experience as a Registered Nurse
 </li>
 <li>
 Required - 1 year Home Health Clinical Experience as an RN.
 </li>
 <li>
 Required - 1 year demonstrated proficiency in Home Health OASIS Review including all types of OASIS.
 </li>
 <li>
 Required - 1 year Experience with an Electronic Medical Record (EMR) system.
 </li>
 <li>
 Preferred - OASIS Certification.
 </li>
 <li>
 Preferred &ndash; Experience using Homecare Homebase (HCHB) EMR.
 
 
 </li>
 </ul>
 
 Certifications, Licenses, and Registrations
 
 
 
 <ul>
 <li>
 Required &ndash; Must be a licensed Registered Nurse in state of California.
 
 
 </li>
 </ul>
 Compensation range: $80,000 - $90,000
 
 
 
 The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.
 
 
 
 Compassus offers a comprehensive benefits package including, Medical, Dental, Vision, 401k and much more.
 
 
 At Compassus, including all Compassus affiliates, diversity, equity, and inclusion are fundamental to our Pillars of Success. We are committed to creating a fair work environment where our team members feel welcomed, highly valued, and respected. As an equal opportunity employer, all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
 
 
 
 Build a Rewarding Career with Compassus
 
 
 
 At Compassus, we care for our team members as much as we care for our patients and their families. Through our Care for Who I Am culture, we show compassion, respect, and appreciation for every individual. Embark on a career that cares for you while you care for others.
 
 
 
 Your Career Journey Matters
 
 
 
 We&rsquo;re dedicated to helping you grow and succeed. Whether you&rsquo;re pursuing leadership roles, specialized training, or exploring new career paths, we provide the tools and support you need to thrive.
 
 
 
 The Compassus Advantage
 
 
 
 <ul>
 <li>
 Meaningful Work: Make an impact every day by honoring the quality of life of our patients, supporting them and their families with compassion, and creating moments that truly matter.
 </li>
 <li>
 Career Development: Access leadership pathways, mentorship, and personalized professional development.
 </li>
 <li>
 Innovation Meets Compassion: Collaborate with a supportive team using the latest tools and technologies to deliver exceptional care.
 </li>
 <li>
 Enhanced Benefits: Enjoy competitive pay, flexible time off, tuition reimbursement, and wellness programs designed for your well-being.
 </li>
 <li>
 Recognition and Support: Be celebrated for your contributions through recognition programs that honor your dedication.
 </li>
 <li>
 A Culture of Belonging: Thrive in a culture where you can be your authentic self, valued for your unique contributions and supported in a community that embraces diversity and inclusion.
 
 
 </li>
 </ul>
 
 Ready to Join?
 
 
 
 At Compassus, your career is more than a job&mdash;it&rsquo;s an opportunity to make a lasting impact. Take the next step and join a team that empowers you to grow, innovate, and thrive.
 
 
</div>

Clinical Documentation Specialist RN

Preventive Measures

<div>Summary: The Clinical Documentation &amp; Claims Compliance Specialist is responsible for reviewing clinical documentation and billing data to ensure services meet payer requirements and organizational compliance standards. This role supports the Billing Department by verifying authorizations, documentation accuracy, and claim readiness prior to submission. The specialist conducts quality assurance reviews to identify documentation deficiencies, authorization issues, and billing errors that may result in claim denials. This position works collaboratively with clinical staff, billing teams, and leadership to ensure accurate claim submission, minimize denials, and maintain compliance with Medicaid and payer regulations, including DC Medicaid billing requirements. 
Role: Lead, Manage, Accountability (LMA) 
Primary Job Responsibilities:<ul><li>Verify documentation supports billed CPT codes and services rendered.</li><li>Review clinical documentation to ensure services meet payer billing requirements.</li><li>Identify incomplete, late, or non-compliant documentation prior to billing.</li><li>Perform quality assurance reviews of claims to ensure accuracy prior to submission.</li><li>Confirm correct CPT codes, modifiers, diagnosis codes, and rendering provider information.</li><li>Verify authorization numbers and service approvals in payer portals prior to billing.</li><li>Ensure services billed align with approved authorizations and service limits.</li><li>Analyze denied claims to identify root causes related to documentation or billing errors.</li><li>Monitor denial trends and recommend corrective actions.</li><li>Maintain tracking logs for documentation reviews, authorizations, and claim errors.</li><li>Prepare weekly or monthly reports summarizing QA findings and trends.</li><li>Assist with internal compliance reviews and audit preparation.</li><li>Provide feedback to clinical staff on documentation requirements and compliance standards.</li></ul> 
Job Skills:<ul><li>Understanding of CPT, ICD-10, and healthcare billing practices.</li><li>Knowledge of Medicaid billing requirements and payer compliance rules.</li><li>Strong attention to detail and analytical skills.</li><li>Proficiency in Excel for tracking and reporting.</li><li>Ability to work independently while collaborating with clinical and billing teams.</li></ul> 
Education/Experience:<ul><li>Associate&rsquo;s or Bachelor&rsquo;s degree in healthcare administration, Health Information
</li><li>Management, Business Administration, or a related field preferred.</li><li>Experience</li><li>2+ years of experience in healthcare billing, clinical documentation review, or revenue</li><li>cycle operations.</li><li>Experience with Medicaid billing and authorization processes preferred.</li><li>Experience working with electronic health record (EHR) systems.</li></ul> 
Core Values:<ul><li>Do the Right Thing - We approach decisions with integrity, honesty, and transparency.</li><li>Own It - We take full responsibility for our role, commitments, and performance.</li><li>Serve First - We show up with a mindset of service to colleagues, clients, and the mission.</li><li>Choose Solutions - We display a solution-oriented mindset and bring constructive energy to</li></ul>
 challenges.<ul><li>Lead with Respect - We treat everyone with respect, communicate professionally, and handle</li></ul>
 conflict maturely.<ul><li>Commit to the Goal - We demonstrate focus, follow-through, and accountability to team</li></ul>
 objectives.</div>

Clinical Documentation & Claims Compliance Specialist

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

Southeastern Cardiology

<div>Description:

At Southeastern Cardiology Associates, our Medical Scribes are not just documenters; they are the right-hand to our specialized physicians. This role allows our providers to focus 100% on patient care. This role is designed for a professional who thrives on clinical preparation, data synthesis, and high-level execution. 
Daily Responsibilities<ul><li>
Chart-prepping and reviewing medical records to ensure the physician is fully briefed before the first patient arrives.</li><li>
Review test results, interpretations, and medical history to provide the physician with a comprehensive overview prior to entering the exam room.</li><li>
Act as the documentation lead, capturing patient history, physical exams, and dictated diagnoses in real-time while retrieving necessary reports so the physician can remain patient focused.</li><li>
Finalize documentation, manage interoffice communications for orders, medicine refills, and coordination of future scheduling needs to close the loop on patient care.</li></ul>
Requirements:

 Qualifications &amp; Skills<ul><li>
Active Georgia LPN or RN license, or active Certification in Medical Assisting (CMA)</li><li>
Active BLS required</li><li>
ACLS required for RN candidates</li><li>
Strong proficiency in EMR systems and cardiac-related knowledge</li>
Ability to maintain legal and ethical standards (AMA, CMS, ICD-10, &amp; HIPAA) 
<li>
</li></ul>Full-Time Benefits &amp; Perks<ul><li>
Set scheduled 4-day work week</li><li>
Comprehensive Medical, Dental, and Vision insurance (effective 1st of the month following 60 days)</li><li>
Company-paid Long-Term Disability (60%) and $25,000 Basic Life Insurance</li><li>
6 Paid Holidays: New Year&rsquo;s Day, Memorial Day, 4 of July, Labor Day, Thanksgiving, &amp; Christmas</li><li>
PTO accrued at 3.08 hours per paycheck (80 hrs/yr)</li><li>
401k matching program after 1 year worked</li><li>
VIP Status at both Southeastern Cardiology and Southeastern Gastroenterology</li><li>
Discounts through Uniforms of America, and the Working Advantage program.</li></ul></div>

CMA, LPN, RN Medical Scribe- Clinical Documentation

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Clinical Documentation Specialist - Sepsis Coordinator

CMA, LPN, RN Medical Scribe- Clinical Documentation