Registered Nurse Clinical Documentation Informaticist

Overview

NAH reserves the right to make hiring decisions based on applicants' state of residence if outside the state of Arizona. NAH currently hires for remote positions in the following states: 

• Alabama
• Arizona
• Florida
• Georgia
• Idaho
• Indiana
• Kansas
• Michigan
• Missouri
• North Carolina
• Ohio
• Oklahoma
• Pennsylvania
• South Carolina
• Tennessee
• Texas

The Clinical Documentation Information Specialist works to facilitate complete and comprehensive documentation reflective of clinical treatment, diagnosis, accurate severity of illness and risk of mortality. He/she works with a multi-disciplinary team to achieve this goal.

Responsibilities

Clinical* Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnoses, impact of procedures on DRG and is able to impart this knowledge to physicians and other health team members.* Demonstrates and utilizes the guidelines of care and practice via the nursing process and in accordance with Arizona State Board of Nursing Laws and Regulations being able to perform at a fully competent level.* Maintains a review rate of 80% on assigned cases and query rate of 15% on assigned cases, or as determined by clinical performance need. Performs audits of documentation to ensure consistency and that standards are met.  Operations* Communicates with physicians face-to-face or through clinical documentation inquiry forms to clarify information, obtain needed documentation, present opportunities and educate for appropriate MS-DRG based on severity of illness.* Confers with HIM coders to ensure appropriate MS-DRG assignment and completeness of supporting documentation.* Confers with Physician Advisor as needed.  Data intergrity* Conducts concurrent and retrospective review of each assigned patient in the time frame and frequency as required.* Identifies and records the most appropriate principal diagnosis, secondary diagnosis, complications/co-morbidities and procedures to reflect the severity of illness and risk of mortality.* Identifies opportunities for improvement in documentation processes.* Communicates with physicians face-to-face or through clinical documentation inquiry forms to clarify information, obtain needed documentation, present opportunities and educate for appropriate MS-DRG based on severity of illness.* Maintains accurate data in the tracking database to identify trends and issues, developing action plans to achieve team goals.  Compliance/Safety* Responsible for reporting any safety-related incident in a timely fashion through the Midas/RDE tool; attends all safety-related training programs; performs work in a safe manner; monitors work environment for possible safety issues and ensures others are also performing work in a safe manner.* Stays current and complies with state and federal regulations/statutes and company policies that impact the employee's area of responsibility.* If required for the position, ensures all certifications and/or licenses are up-to-date and valid prior to expiration dates.* Completes all company mandatory modules and required job-specific training in the specified time frame.

Qualifications

Education

• Associates RN, RHIA/RHIT, or Bachelor's Degree with experience/certification in Coding/CDI - Required
• BSN - Preferred

  Certification & Licensures

• CCDS- Required after 2 years experience
• Current RN License (does not have to be AZ)- Required

Experience

• 3-5 years clinical documentation specialist, coding, or UR experience- Preferred
• Supervisory, education, or leadership experience- Preferred

Healthcare is a rapidly changing environment and technology is integrated into almost all aspects of patient care. Computers and other electronic devices are utilized across the organization and throughout each department. Colleagues must have an understanding of computers, and competence in using computers and basic software programs.