RN Clinical Documentation Informaticist

This is a fully remote position, open to applicants in Alabama, +13 more states.

📋 Description

• Facilitate thorough and comprehensive clinical documentation that accurately reflects clinical treatment, diagnosis, illness severity, and mortality risk.

• Collaborate with a multidisciplinary team to enhance clinical documentation practices.

• Utilize knowledge of complications, comorbidities, illness severity, mortality risk, case mix, secondary diagnoses, and the impact of procedures on DRG.

• Review assigned cases and conduct documentation audits to ensure consistency and adherence to standards.

• Communicate with physicians to clarify information, obtain necessary documentation, identify opportunities, and provide education on proper MS-DRG assignment.

• Work with HIM coders to guarantee appropriate MS-DRG assignment and complete supporting documentation.

• Consult with the Physician Advisor as required.

• Perform concurrent and retrospective reviews of assigned patients.

• Identify and document principal and secondary diagnoses, complications/comorbidities, and procedures.

• Recognize opportunities to enhance documentation processes.

• Maintain accurate data in the tracking database, identify trends and issues, and create action plans.

• Report safety-related incidents, participate in safety training, and monitor the work environment for safety concerns.

• Stay updated with relevant state and federal regulations as well as company policies.

⛳️ Requirements

• Associate's degree with RN, RHIA/RHIT, or a bachelor's degree along with experience/certification in Coding/CDI — required.

• BSN preferred.

• CCDS certification required after 2 years of experience.

• A current RN license is required; the license does not have to be from Arizona.

• 3–5 years of experience as a clinical documentation specialist, in coding, or in utilization review preferred.

• Supervisory, educational, or leadership experience preferred.

• Proficient understanding of computers and adeptness in using basic software programs.

• Ability to comply with Arizona State Board of Nursing Laws and Regulations.

• Capability to maintain current certifications and/or licenses.

• Ability to complete mandatory modules and job-specific training within designated timeframes.

🏝️ Benefits

• Regular full-time employment (40 hours).

• Remote work opportunities available in eligible states.

• Company-provided mandatory and job-specific training.