Clinical Documentation Integrity Specialist- RN- Remote

Beth Israel Lahey Health; Winchester (MA); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization is seeking a qualified candidate for a remote role in clinical documentation. Responsibilities include reviewing patient records, ensuring accurate documentation, and collaborating with healthcare providers. The ideal candidate holds an RN license, has 3-5 years of experience in clinical nursing, and is proficient in coding guidelines. This position offers competitive salary and benefits, emphasizing career advancement and meaningful work in patient care.

Benefits

Career advancement opportunities

Health coverage

Retirement plans

Qualifications

• 3-5 years of related work experience in clinical nursing practice.
• Proficiency in computer systems and web-based applications.
• Strong understanding of inpatient coding guidelines.

Responsibilities

• Complete initial reviews of patient records within 24-48 hours.
• Conduct follow-up reviews every two days and query physicians.
• Educate healthcare providers on clinical documentation improvement.

Skills

Clinical documentation improvement

Patient care

Coding guidelines

Computer systems

Education

Associate's degree

Bachelor's degree

RN license

Tools

Microsoft Office

Job description

Overview

Employer Industry: Healthcare

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Benefits

• This position is fully remote, providing flexibility in your work environment.
• Opportunity for career advancement and growth within the organization.
• Work within a collaborative environment that emphasizes improvement in patient care.
• Engage in meaningful work that impacts patient documentation and healthcare quality.
• Competitive salary and benefits package, including health coverage and retirement plans.

Responsibilities

• Complete initial reviews of patient records within 24-48 hours of admission to ensure accurate documentation.
• Evaluate documentation to assign principal and secondary diagnoses for proper DRG assignment.
• Conduct follow-up reviews every two days and query physicians for any missing or unclear documentation.
• Educate healthcare providers on clinical documentation improvement and best practices.
• Collaborate with an interdisciplinary team to enhance the quality of medical record documentation.

Qualifications

• Associate’s degree required; Bachelor's degree preferred.
• RN license is required.
• 3-5 years of related work experience in clinical nursing practice, including medical, surgical, and/or ICU settings.
• Proficiency in computer systems and web-based applications, including Microsoft Office.
• Strong understanding of inpatient coding guidelines.

Preferred Qualifications

• BS in Nursing with 5-8 years of acute care clinical experience.
• Certified Clinical Documentation Specialist (CCDS) or Certified Clinical Documentation Improvement Professional (CDIP).
• Experience with DRG Reimbursement and ICD-10 Coding.

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