Registered Nurse Clinical Documentation Specialist

Ascension; Milwaukee (WI); Remote; USD 80,000 - 111,000; Full time

Benefits offered by this job

Health coverage

403(b) retirement plan

PTO and holidays

Tuition reimbursement

Employee Assistance Program

Parental leave

Pet insurance

Job summary

Ascension is seeking a Clinical Documentation Specialist to join the Clinical Integrity Documentation team in a remote, full-time capacity. The role focuses on admission reviews, DRG assignment, and ensuring documentation supports severity of illness and level of service.

You will collaborate with physicians to obtain detailed information, maintain accurate review records, and help ensure compliant medical records prior to discharge.

Qualifications

• AHIMA/AAPC credential obtained before hire date.
• Wisconsin-registered nurse or multi-state Compact license obtained before hire date.
• Clinical Documentation Specialist experience preferred.

Responsibilities

• Complete admission reviews and assign a working DRG; enter data in the CDI database.
• Initiate and maintain interactions with physicians to obtain detailed medical information.
• Collaborate with healthcare professionals to ensure accuracy of illness severity and level of services; resolve physician queries before discharge.
• Maintain accurate records of review activities and report CDI outcomes.

Skills

AHIMA credentials

Nursing licensure

Clinical documentation

Education

High School diploma or equivalent with 2 years experience

Associate's or Bachelor's degree

4 years cumulative job experience

5+ years ICU/ED nursing experience

Clinical Documentation Specialist experience

Job description

Your future role at a glance

Location: Remote

Facility: Ascension Wisconsin Hospitals

Department: Clinical Integrity Documentation

Schedule: Days | Full-Time

Salary Range: $79,511.52-$110,834.59

How you’ll make an impact in this role

• 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.
• Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
• 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.
• Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.

What Minimum Requirements You’ll Need

• One or more of the following required:
  • Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
  • Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
  • Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
  • Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.
  • Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
  • Licensed Registered Nurse credentialed from the Wisconsin Board of Nursing or current home state license for multi-state license recognition "Compact State" obtained prior to hire date or job transfer date.

Education

• 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.
• 5 or more years of nursing experience in ICU and/or Emergency Department
• Previous Clinical Documentation Specialist experience

Benefits that help you thrive

• Comprehensive health coverage: medical, dental, vision, prescription coverage and HSA/FSA options
• Financial security & retirement: employer-matched 403(b), planning and hardship resources, disability and life insurance
• Time to recharge: pro-rated paid time off (PTO) and holidays
• Career growth: Ascension-paid tuition (Vocare), reimbursement, ongoing professional development and online learning
• Emotional well-being: Employee Assistance Program, counseling and peer support, spiritual care and stress management resources
• Family support: parental leave, adoption assistance and family benefits
• Other benefits: optional legal and pet insurance, transportation savings and more

Life at Ascension: Where purpose meets opportunity

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'll find an inclusive and supportive environment where your contributions truly matter.

Equal employment opportunity employer

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.

Fraud prevention notice

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.

E-Verify statement

Employer participates in the Electronic Employment Verification Program. Please click here for more information.