Clinical Documentation Specialist, RN

This is a fully remote position, open to applicants in Louisiana.

📋 Description

• Enhance the integrity of medical record documentation through collaboration with healthcare providers.

• Support accurate representation of illness severity, mortality risk, acuity, and care complexity.

• Conduct pre-visit and retrospective assessments of ambulatory clinical documentation.

• Ensure precise representation of patient complexity to bolster the facility’s Risk Adjustment strategy.

• Utilize clinical and nursing expertise, CMS coding standards, DRG principles, HCC documentation needs, ICD-10-CM accuracy and specificity, as well as medical necessity criteria.

• Work in partnership with physicians and advanced practice providers.

• Convey documentation improvement opportunities.

• Instruct patient care team members on documentation protocols, coding requirements, and specific service-line criteria.

⛳️ Requirements

• Graduate of an accredited School of Nursing.

• A valid Louisiana Registered Nurse License is mandatory.

• Minimum of five (5) years of clinical experience in an acute or ambulatory care environment.

• Familiarity with ICD-10 coding principles and guidelines, as well as Risk Adjustment Coding.

• Proficient in Microsoft Office applications (PowerPoint, Excel, Word).

• Experience with 3M software and Encoder.

• Outstanding written and verbal communication abilities.

• Strong critical thinking and interpersonal skills.

• Comprehensive knowledge of complex disease processes with extensive clinical experience in an outpatient setting.

• Capability to work independently with minimal supervision and a self-motivated attitude.

• Strong organizational and planning skills.

• Good physical health.

• Ability to stand, sit, or walk for extended periods.

• Capacity to lift a minimum of 20 pounds.

• Ability to work in a moderately noisy environment.

• Preferred: Bachelor of Science degree in Nursing.

• Preferred: Experience with Medicare risk adjustment, Hierarchical Condition Categories, coding, billing, and auditing.

• Preferred: Current Certified Clinical Documentation Specialist (CCDS) certification through ACDIS.

🏝️ Benefits

• Fully remote work arrangement.

• Competitive compensation package.

• Full-time schedule of 40 hours per week.

• Monday to Friday work schedule.

• Employee support aligned with mission, vision, and values.

• Equal employment opportunity.