Registered Nurse Clinical Documentation Specialist

Socket.dev; Shorewood (WI); Hybrid; USD 80,000 - 111,000; Full time

Benefits offered by this job

PTO

Health insurance options

Job summary

Ascension Wisconsin Hospitals is seeking a Clinical Documentation Improvement (CDI) Specialist to review admissions, assign DRGs, and ensure proper documentation in the CDI database. You will collaborate with physicians and mid-level providers to obtain necessary information before discharge.

Minimum qualifications include 5+ years in ICU/ED nursing and AHIMA credentials or equivalent, with Wisconsin RN license or multi-state recognition.

Qualifications

• 5+ years nursing experience in ICU and/or Emergency Department.
• Previous Clinical Documentation Specialist experience preferred.
• Licensure/Certification/Registration in AHIMA or equivalent required prior to hire.

Responsibilities

• Complete admission reviews and assign a working DRG.
• Interact with physicians to obtain detailed information for medical records.
• Ensure severity of illness and services are accurately reflected before discharge.
• Maintain records of review activities and CDI outcomes.

Skills

Nursing experience

Collaboration with physicians

Education

AHIMA credential or equivalent

RN license (Wisconsin) or multi-state license

High School diploma or higher

Tools

CDI database

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 qualifications you'll need

Licensure / Certification / Registration:

• 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.

What additional requirements you'll need

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

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 97,000+ 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

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.

Employer does not participate in E-Verify and therefore cannot employ STEM OPT candidates.

Benefits

Paid time off (PTO)Various health insurance options & wellness plansRetirement benefits including employer match plansLong-term & short-term disabilityEmployee assistance programs (EAP)Parental leave & adoption assistanceTuition reimbursementWays to give back to your community

Benefit options and eligibility vary by position. Compensation varies based on factors including, but not limited to, experience, skills, education, performance, location and salary range at the time of the offer.