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

📋 Description

• Assess clinical documentation for completeness and quality.

• Facilitate modifications to clinical documentation by communicating with physicians, practitioners, and medical records coding staff.

• Ensure that relevant patient conditions and treatments are accurately documented for proper reimbursement using DRG-based Medicare methodology.

• Verify the precision and thoroughness of clinical information used for measuring and reporting patient care, physician practices, and medical center outcomes.

• Educate members of the patient care team on the importance of clinical documentation.

• Conduct initial and follow-up audits and investigations of medical records.

• Analyze and report on institutional practices and procedures regarding compliance, operational efficiency, and record accuracy.

• Collaborate with physicians, coding specialists, and others to clarify information and secure necessary documentation.

• Guide providers on documentation, coding, reimbursement, and performance improvement methodologies.

• Lead or engage in Oncology QA studies and special projects.

• Serve on or chair committees and task forces.

⛳️ Requirements

• Valid licensure as a Registered Nurse in Washington State.

• Bachelor's Degree in Nursing.

• Minimum of 6 years of inpatient Oncology nursing experience.

• At least 2 years of Clinical Documentation Improvement (CDI) experience.

• CCDS and/or CDIP certifications preferred.

• Strong communication skills.

• Excellent critical thinking and problem-solving abilities.

• Equivalent education and/or experience may be considered in lieu of minimum qualifications, except where legal requirements such as a license, certification, and/or registration are mandated.