Nurse – Clinical Documentation Integrity, PACE

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

📋 Description

• Assess current medical records and approved clinical intelligence reports to pinpoint documentation opportunities for provider evaluation.

• Examine provider notes, hospital records, emergency department reports, skilled nursing documentation, specialist notes, medication profiles, lab results, imaging, assessments, care plans, and prior documentation.

• Utilize clinical documentation and coding expertise, including experience focused on CC coding, while analyzing documentation opportunities.

• Detect documentation deficiencies regarding condition status, specificity, acuity, chronicity, complications, treatment, monitoring, and clarity of assessment or planning.

• Draft clear, unbiased clinical summaries for provider assessment.

• Present supporting documentation by date, location, and type without directing the provider towards a specific diagnosis or code.

• Assist in provider workflow during annual, semiannual, high-risk, complex care, and post-discharge visits.

• Facilitate appropriate non-leading clarification when documentation appears incomplete, inconsistent, or unclear.

• Educate providers and clinical teams on documentation completeness, specificity, provider charting, and audit readiness.

• Monitor documentation patterns, recurring deficiencies, and areas for enhancement.

• Engage in quality reviews, compliance evaluations, and audit-readiness initiatives.

• Collaborate with coding, risk adjustment, compliance, clinical leadership, and provider teams to enhance documentation workflows.

• Provide functional oversight and direction to Medical Assistants in documentation preparation.

• Assist in developing and refining standardized workflows, work queues, templates, prioritization criteria, and turnaround expectations.

• Deliver onboarding, training, competency validation, coaching, and feedback to Medical Assistants.

• Review samples of MA-prepared documentation for accuracy, completeness, neutrality, organization, and timeliness.

• Supervise documentation preparation workload, completion rates, rework, quality findings, and obstacles.

• Identify opportunities to enhance and expand the CDI program.

• Collaborate with leadership to establish best practices, processes, and standards.

• Report privacy issues, unsupported documentation, non-neutral language, or compliance concerns through established channels.

• Participate in quality improvement initiatives and ongoing training.

• Uphold confidentiality and maintain a secure, private remote workspace.

• Join virtual meetings and ensure consistent communication with providers, leadership, and clinical teams.

• Travel between centers or other locations as required.

• Do not independently diagnose participants or select, assign, sequence, recommend, or submit diagnostic data.

• Assist in structuring, developing workflows, identifying opportunities, and establishing best practices as the CDI program evolves.

⛳️ Requirements

• Active, unrestricted Registered Nurse license in the relevant state.

• 3 to 5 years of clinical nursing experience minimum.

• Required previous experience in Clinical Documentation Integrity, provider documentation, coding, risk adjustment, or a related role.

• Required prior experience reviewing provider charts and clinical documentation.

• Required demonstrated coding experience with a focus on CC.

• Strong understanding of provider documentation and charting practices is essential.

• Required experience reviewing electronic medical records and clinical documentation.

• Strong clinical judgment and comprehension of clinical documentation standards.

• Solid understanding of provider charting and clinical documentation practices.

• Proficient computer and electronic medical record skills are necessary.

• CPR and First Aid Certification (or willingness to obtain post-hire — training provided).

• Preferred experience working with older adults, medically complex participants, chronic disease management, PACE, home-based care, or community-based care.

• Preferred experience in providing training, coaching, quality review, or workflow oversight to Medical Assistants or other clinical support staff.

• Experience with PACE, Medicare Advantage, value-based care, clinical documentation integrity, quality, audit, or risk adjustment is a plus.

• Ability to maintain confidentiality and protect sensitive participant information.

• Ability to maintain a private and secure workspace while working remotely.

• Capability to work independently and manage priorities in a remote setting.

• Must be able to participate in virtual meetings and maintain consistent communication with providers, leadership, and clinical teams.

• Must be willing to travel between centers or other locations as necessary.

• Successful completion of required background checks, health and safety screenings, and any clearances needed for healthcare programs is essential.

• Must be able to sit and work at a computer for extended periods.

• Must be capable of moving intermittently throughout the workday.

• Must remain focused and attentive while reviewing detailed clinical information.

• Must be able to utilize standard office and computer equipment.

🏝️ Benefits

• 9 Paid Holidays

• PTO starting at 3 weeks + 1 day per year (accrued from date of hire for full-time employees)

• Medical, Dental, & Vision

• Free Life and AD&D Insurance Plan

• Health Savings and Flexible Spending Accounts

• Short Term Disability Insurance

• Group Voluntary Term Life Insurance for Employees, Spouses, and Dependents

• Paid Parental Leave

• Tuition Reimbursement and Paid Training Opportunities

• Retirement Plan with company annual match

• Mileage Reimbursement at the annual IRS rate as applicable

• Training, mentorship, and career development programs