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Clinical Documentation Integrity Nurse
| Company | Intermountain Healthcare |
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| Location | Las Vegas, NV, USA |
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| Salary | $43.98 – $63.79 |
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| Type | Full-Time |
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| Degrees | Bachelor’s |
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| Experience Level | Senior |
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Requirements
- Bachelor’s degree in nursing (BSN) from an accredited institution (degree will be verified)
- Current RN License in state of practice
- Demonstrated clinical nursing experience in a diverse setting
- Demonstrated experience in clinical documentation integrity and/or outpatient coding
- Demonstrated experience in chart reviews and/or auditing
- Strong communication skills to effectively convey complex ideas
- Ability to thrive in a fast-paced environment and manage multiple tasks simultaneously
- Ability to work independently with minimal supervision
- Proficient in using Electronic Medical Record (EMR) tools
Responsibilities
- Ensure clinical documentation is accurate, specific, complete, and compliant to reflect the severity of illness and risk of mortality of the patient
- Work collaboratively with providers to identify opportunities for the accuracy and quality of chart documentation
- Identify complications and co-morbid conditions, specify co-existing and causal conditions, and follow up with providers responsible for the care of the patient for appropriate documentation
- Identify the need to clarify documentation in the medical record by communicating with providers face-to-face or in written communication
- Stay abreast of coding guidelines, risk adjustment payment methodologies, regulatory compliance, and quality-based programs
- Maintain thorough and current knowledge of clinical care and treatment options to critically assess the accuracy and appropriateness of documentation
- Demonstrate excellent communication and interaction skills to diplomatically handle difficult, complex, and/or potentially political situations with physicians, office staff during clinic in-person on-site work, and other external and internal customers and departments
- Serve as a resource for providers to educate on linking coding guidelines and medical terminology to capture opportunities
- Perform other duties as assigned, including but not limited to the orientation of caregivers
Preferred Qualifications
- Five (5) years of clinical nursing experience in a diverse setting
- Demonstrated clinical experience in ICU, primary care, admissions, and discharges
- Proficient in Microsoft Office Suite
