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Registered Nurse, RN | Clinical Documentation Specialist

Gundersen Health System • Full-time • Home - Wisconsin, United States of America • 6d ago

Love + medicine is who we are, it's what we do, it's why people want to work here. If you’re looking for a job to love, apply today.

Schedule Weekly Hours:

Gundersen Health System is looking for a full-time RN (1.0 FTE) to work as a Clinical Documentation Improvement Specialist in La Crosse, WI. This is your opportunity to do the work you love in the beautiful Coulee region.

What you will do:

Work full-time (40 hours/week) in this salaried position
Work closely with medical staff to ensure that documentation for hospitalized patients is recorded according to regulatory guidelines and quality indicators. 
After successful orientation on-site, this position will be a work-from-home position with on-site morning rounding twice per week

What you will get:

No work on weekends and holidays
Top-rated retirement and healthcare benefits
Support to grow your career with access to our Career Development Center and Tuition Investment Program

What you need:

Bachelor’s Degree in Nursing
3 years of nursing experience in training/education
3 years of inpatient hospital nursing experience
RN licensure in the state of Wisconsin upon hire

Gundersen Health System is healthcare for neighbors, by neighbors. While we call La Crosse home, our system has 7 hospitals and 65 clinics in neighboring communities. Inside our walls and our neighborhoods, we deliver world-class medical care combined with the right amount of love. We call it Love + Medicine and it’s who we are.

You may be asked to complete an on-demand video interview (powered by HireVue) as a first step in the process.

Job Description:

The RN-Inpatient Clinical Documentation Specialist (CDS), working under the direction of the Supervisor, Hospital Inpatient Coding and CDI Services and the physician leaders of the Clinical Documentation Improvement Services (CDIS), utilizes clinical expertise to identify and facilitate modifications to quality and completeness of medical record documentation of medical and associate staff. Through concurrent evaluation and assimilation of the objective and subjective data documented in inpatient medical records along with extensive daily interactions with physicians, associate staff, house staff and multidisciplinary team members, the CDS will be responsible for educating providers to achieve improved documentation results for the organization. The outcome will be documentation that accurately and completely captures the clinical picture/level of severity of the patient while providing accurate and complete information to be utilized in coding, profiling and outcomes reporting of both the Hospital and the Physicians. The CDS utilizes knowledge of national coding guidelines (ICD-9/ICD-10), various DRG systems, standards of compliance, and clinical expertise to identify opportunities and achieve results.

Major Responsibilities:
1. Demonstrates knowledge of documentation requirements and coding guidelines that recognize severity of illness and medical necessity. Improves the overall quality and completeness of clinical documentation by performing systematic chart reviews on a daily basis. Identifies the most appropriate principal diagnosis and secondary diagnoses to accurately reflect patient care.
2. Confers with medical and associate staff face-to-face or through standard clarification systems to facilitate modification of clinical documentation and to reinforce education regarding the significance of appropriate documentation. Serves as a resource to the professional staff, assuring compliance with all national coding guidelines and governmental regulations regarding physician documentation.
3. Achieves and maintains current knowledge and understanding of ICD-10 coding guidelines and various DRG systems (DRG, CC, and MCC),through participation in education and training, including reading and comprehension of AHA Coding Clinic.

4. Maintains daily workload such as but not limited to: new hospital admissions, daily reviews of patients currently admitted, patient discharges, clarifications to physicians teams, mortality reviews, and sepsis reviews.

5. In partnership with CDI physician leaders, develops curriculum and delivers education to the medical staff and other clinicians using a variety of teaching methods includingincluding regular rounding with hospital inpatient services, and small group presentations at department and section meetings.
6. Confers and collaborates with Hospital Coding Specialists to deepen their understanding of pathophysiology, severity of illness in support of accurate and compliant code assignment. Performance is consistent with the Code of Ethics of the American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS).
7. Develops and reports performance measures for the medical staff, Executive Committee and Administration.
8. Consistently utilizes monitoring tools to track the progress of the Clinical Documentation Improvement Program. Interprets monthly tracking reports of findings and identifies and acts on opportunities for improvement.
9. Assists service line directors, department chairs and section chiefs with documentation to improve risk-adjusted statistics, national profiles and benchmarking.
10. Maintains flexibly, adjusting work time and availability to fulfill the program goals, achieve outcomes and meet the needs of the medical staff.
11. Adheres to regular and predictable attendance.

12. Performs other job-related responsibilities as requested or assigned.

Education and Learning:
REQUIRED
Bachelor's degree in Nursing

DESIRED
ICD Diagnosis and Procedure Coding Training demonstrated by certificate of completion.

Work Experience:
REQUIRED
3-4 years nursing experience with proven experience in training/education

DESIRED
5-7 years of nursing, preferred Inpatient nursing, including one year work experience in clinical documentation improvement, or directly related experience.

License and Certifications:
REQUIRED
Registered Nurse (RN) licensed minimally in the state of practice, some positions may require additional state RN licenses.

DESIRED
Certified Coding Specialist (CCS) or Certified Clinical Documentation Specialist (CCDS) or Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) or Certified Coding Specialist - Physician Based (CCS-P) or American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) or any certification in coding or clinical documentation improvement

Age Specific Population Served:
Nonage Specific (N/A)

OSHA Category:
Category III - No employees in this job title have a reasonably anticipated risk of occupational exposure to blood and/or other potentially infectious materials.

Environmental Conditions:
Exposed to infectious diseases.

Physical Requirements/Demands Of The Position:
Sitting Frequently (34-66% or 5.5 hours)
Walking/Standing Frequently (34-66% or 5.5 hours)

If you need assistance with any portion of the application or have questions about the position, please contact HR-Recruitment@gundersenhealth.org or call 608-775-0267

Equal Opportunity Employer

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