Clinical Documentation Nurse

CentraCare; Oregon; Hybrid; USD 89,000 - 133,000; Full time

Benefits offered by this job

Medical benefits

PTO

Tuition reimbursement

Job summary

CentraCare Health is seeking a qualified Clinical Documentation Nurse to join our team. The role focuses on concurrent auditing of medical record documentation to reflect care provided and resources used, with proactive clarification from physicians and staff to ensure accuracy of severity of illness and mortality risk.

The position offers full-time hours (80 per pay period) with remote work after training, 8-hour shifts between 6am–5pm, and occasional travel to CentraCare sites.

Qualifications

• Bachelor's degree in nursing is required.
• Current RN licensure in Minnesota is required.
• Minimum of 3 years acute care experience.
• Performance improvement experience preferred.
• CCD S National Certification as Clinical Documentation Specialist (CCDS) preferred.
• ACDIS CDI Apprenticeship preferred.

Responsibilities

• Audit medical record documentation concurrently to evaluate care and resource use.
• Solicit clarification from physicians and staff when documentation is unclear.
• Share audit results with staff and management for process improvement.

Skills

Critical Thinking

Quality improvement

Education

Bachelor's degree in nursing

Job description

CentraCare is looking for a qualified Clinical Documentation Nurse to join our team! This role is responsible for concurrent auditing of medical record documentation to evaluate the documentation and utilization review of services to adequately reflect care provided and resources used. Responsibilities include facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Proactively solicits clarification from physicians and clinical staff in areas where further specificity is needed in the documentation, and consults with attending physician when conflicting information appears in the medical record. Maintains documentation regarding results of audit activity and shares those with staff and management as necessary. Collects and analyzes data pertinent to documentation findings and outcomes for process improvement. This position supports the concepts and philosophies of nursing as well as sound business practices. Promotes and facilitates education to providers regarding disease processes. Communicates with appropriate healthcare team members to promote accurate and complete documentation of each patient encounter.

Schedule

Full-time | 80 hours every two weeks | Remote after trainingDays | 8-hour shifts | Working hours between 6am- 5pmOccasional travel to CentraCare site required

Pay and Benefits

Starting pay begins at $88,940.80 per year; exact wage determined by years of related experience

Salary range: $88,940.80 - $133,494.40 per year

Salary and salary range are based on a 1.0 FTE, reduced FTE will result in a prorated offer rate

Full-time benefits: Medical, dental, PTO, retirement, employee discounts and more!Tuition reimbursement and college grant programs available

Qualifications

• Bachelor's degree in nursing required
• Current Registered Nurse (RN) licensure in the State of Minnesota required
• Minimum of 3 years acute care experience required
• Performance improvement, quality assurance related experience is required
• Certified Clinical Documentation Specialist National Certification as Clinical Documentation Specialist (CCDS) preferred
• National Certification as a Clinical Documentation Specialist-Outpatient (CCDS-O) preferred
• Candidates who have successfully completed the ACDIS bootcamp for Clinical documentation integrity (CDI) preferred
• Candidates who have completed the ACDIS CDI Apprenticeship preferred
• Utilization review, coding, clinical informatics, case management or critical care experience preferred
• Critical Thinking - must have the ability to process large amounts of information and to evaluate meaning with a rational open mind based on the evidence at hand

CentraCare has made a commitment to diversity in its workforce. All individuals including, but not limited to, individuals with disabilities, are encouraged to apply. CentraCare is an EEO/AA employer.