Senior RN Clinical Documentation Specialist

Department Name:

CDMP Documentation Team-Corp

Work Shift:

Day

Job Category:

Revenue Cycle

Estimated Pay Range:

$39.00 - $65.00 / hour, based on location, education, & experience.

In accordance with State Pay Transparency Rules.

Explore and excel. At Banner Health, health care is a team effort.  One might be surprised by the number of people who work behind the scenes and play a critical role in ensuring the best care for our patients. 

The mission of the Clinical Documentation Improvement Department is to, “ Facilitate concise clinical documentation to appropriately reflect patient acuity, risk of mortality, and resource utilization in order to properly reflect patient care given and optimize organizational goals.”  This mission also supports the accurate translation of diagnoses into ICD-10 codes for patient billing and capture of quality metrics. 

As a successful Senior RN Clinical Documentation Improvement Specialist will need to have at a minimum 2 years of CDI experience. Time in OR, ED or ICU may strengthen a candidates profile.  Level of education may be either registered nurse with active licensure in state worked or graduate of foreign medical school with Doctor of medicine degree.   

This is a fully remote position and available if you live in the following states only: AK, AL, AR, AZ, CA, CO, FL, GA, IA, ID, IN, KS, KY, MI, MN, MO, MS, NC, ND, NE, NM, NV, NY, OH, OK, OR, PA, SC, TN, TX, UT, VA, WA, WI & WY. This position is fully remote with travel less than 15% of the time to either a Banner corporate or hospital site.  With this remote work, candidates must be self-motivated, possess moderate to strong tech skills and be able to meet daily and weekly productivity metrics.    Business hours are Monday-Friday, 8 hour shifts with no weekends or holidays.   

Within Banner Health Corporate, you will have the opportunity to apply your unique experience and expertise in support of a nationally-recognized healthcare leader. We offer stimulating and rewarding careers in a wide array of disciplines. Whether your background is in Human Resources, Finance, Information Technology, Legal, Managed Care Programs or Public Relations, you'll find many options for contributing to our award-winning patient care.

POSITION SUMMARY
This position performs concurrent and secondary clinical chart reviews for defined populations to identify opportunities to improve accuracy of provider documentation and resolve DRG discrepancies. This position is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position is a member of the clinical team responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the diagnostic related group (DRG), severity of illness (SOI), risk of mortality (ROM), risk adjustment, and the complexity of patient care rendered. This position is responsible for reviewing content of the medical record and assisting in the clarification of documentation ambiguities.

CORE FUNCTIONS
1. Completes concurrent and secondary chart reviews of targeted patient populations to identify opportunities to improve accuracy of provider documentation, selection of diagnosis and procedure codes for accurate DRG assignment. Conducts accurate and timely concurrent record reviews, recognizing opportunities for documentation improvement through specialized training and software. Utilizes available resources to formulate clinically credible documentation clarification questions (queries) for members of the clinical team aimed at improving the accuracy of the documentation process which is followed by effective and appropriate communication with Providers and timely follow up on all cases.

2. Provides subject matter expertise related to DRG, clinical documentation opportunities and requirements. Serves as an essential member of the clinical team, emphasizing their role in reviewing content of the medical record, assisting in the clarification of documentation ambiguities. Serves as the liaison between acute care coding and Providers in order to capture accurate DRG, SOI, ROM, risk adjustment, reimbursement, and complexity of patient care rendered.

3. Conducts accurate and timely concurrent record reviews, recognizing opportunities for documentation improvement through specialized training and software. Utilizes available resources to formulate clinically credible and compliant provider documentation clarification (queries) aimed