Clinical Documentation Registered Nurse

CentraCare Health; Saint Cloud (MN); Remote; USD 83,000 - 126,000; Full time

Job summary

CentraCare is hiring a Clinical Documentation Nurse to oversee medical record audits and facilitate accurate documentation of patient care. The role requires a Bachelor's in Nursing, RN licensure in Minnesota, and several years of acute care experience. This is a full-time remote position with occasional travel.

Benefits

Medical, dental, PTO, retirement

Tuition reimbursement and college grant programs

Qualifications

• Minimum of 3 years acute care experience required.
• Certified Clinical Documentation Specialist National Certification preferred.
• Experience in utilization review, coding, or clinical informatics preferred.

Responsibilities

• Responsible for concurrent auditing of medical record documentation.
• Facilitate appropriate documentation from physicians to reflect patient severity.
• Collect and analyze data for documentation findings.

Skills

Critical Thinking

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
• Days | 8-hour shifts | Working hours between 6am- 5pm
• Occasional travel to CentraCare site required

Pay and Benefits:

• Starting pay begins at $83,886.40 per year; exact wage determined by years of related experience
• Salary range: $83,886.40 - $125,840.00 per year
  • Salary and salary range are based on a 1.0 FTE, reduced FTE will result in a prorated offer rate
• Full-timebenefits: 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
• 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.