Nurse - Clinical Documentation Integrity (PACE)

Job Description

Job Description

Do you enjoy using your clinical knowledge to improve documentation, support providers, and help care teams better understand the needs of Participants?

Are you someone who is detail-oriented, collaborative, and committed to accurate, compliant, and Participant-centered care?

If so, you may be the perfect fit for our One Senior Care family of businesses, including LIFE-NWPA, Mountain View PACE, and Buckeye PACE.

Job Summary:

As a Clinical Documentation Integrity Nurse, you’ll support accurate, complete, and compliant provider documentation for medically complex PACE Participants. You’ll review existing medical records, hospital and skilled nursing records, specialist documentation, medications, labs, imaging, assessments, and care plans to identify documentation opportunities for provider review.

This position requires a strong understanding of provider charting, clinical documentation, and coding, with specific experience in CC-focused coding. You’ll prepare neutral clinical summaries, support provider education, and help ensure documentation is complete, specific, and audit-ready.

You’ll also provide functional oversight and guidance to Medical Assistants supporting documentation preparation and help establish consistent workflows, processes, and expectations for this developing program.

This is a new and evolving function, so the ability to work in the grey, use sound judgment, identify opportunities, solve problems, and help build the future structure of the program is essential. You’ll have an opportunity to help create processes, improve workflows, and establish best practices that support providers and Participants across One Senior Care.

This position is ideal for an experienced nurse with previous experience in clinical documentation integrity or a similar provider documentation role who brings strong clinical judgment, coding knowledge, attention to detail, excellent communication skills, and the ability to work independently in an evolving environment.

Schedule:

Remote, Monday through Friday, 8:00 a.m. to 5:00 p.m. Reliable availability is required during scheduled work hours.

Benefits:

• 9 Paid Holidays
• PTO starting at 3 weeks + 1 day per year (accrued from date of hire for full-time employees)
• Medical, Dental, & Vision
• Free Life and AD&D Insurance Plan
• Health Savings and Flexible Spending Accounts
• Short Term Disability Insurance
• Group Voluntary Term Life Insurance for Employee, Spouses, and Dependents
• Paid Parental Leave
• Tuition Reimbursement and Paid Training Opportunities
• Retirement Plan with company annual match
• Mileage Reimbursement at annual IRS rate as applicable

Duties and Responsibilities:

• Review existing medical records and approved clinical intelligence reports to identify documentation opportunities for provider review.
• Review provider notes, hospital, emergency department, and skilled nursing records, specialist
• documentation, medication profiles, labs, imaging, assessments, care plans, and prior documentation.
• Apply clinical documentation and coding knowledge, including CC-focused coding experience, when reviewing documentation opportunities.
• Demonstrate a strong understanding of provider charting and how clinical information should be appropriately documented within the medical record.
• Identify documentation gaps related to condition status, specificity, acuity, chronicity, complications, treatment, monitoring, and assessment or plan clarity.
• Prepare concise, neutral clinical summaries for provider review.
• Present supporting evidence by date, location, and document type without directing the provider to a specific diagnosis or code.
• Support provider workflow during annual, semiannual, high-risk, complex care, and post-discharge visits.
• Facilitate appropriate non-leading clarification when documentation is incomplete, inconsistent, or unclear.
• Provide education to providers and clinical teams regarding documentation completeness, specificity, provider charting, and audit readiness.
• Monitor documentation trends, recurring gaps, and opportunities for improvement.
• Participate in quality reviews, compliance reviews, and audit-readiness activities.
• Collaborate with coding, risk adjustment, compliance, clinical leadership, and provider teams to improve documentation workflows.
• Provide functional oversight and guidance to Medical Assistants supporting documentation preparation.
• Help build and refine standardized workflows, work queues, templates, prioritization criteria, and turnaround expectations for documentation preparation.
• Provide onboarding, training, competency validation, coaching, and feedback to Medical Assistants within the documentation preparation workflow.
• Review samples of MA-prepared documentation for accuracy, completeness, neutrality, organization, and timeliness.
• Monitor documentation preparation workload, completion rates, rework, quality findings, and barriers.
• Help identify opportunities to improve and expand the CDI program as the function continues to develop.
• Work collaboratively with leadership to establish best practices, processes, and standards for the future of the program.
• Escalate privacy concerns, unsupported documentation, non-neutral language, or compliance concerns through established channels.
• Participate in quality improvement initiatives and ongoing training.
• Other duties as assigned.

Everyone’s journey is unique. Even if you haven’t done it all, your dedication to learning and helping others is what counts. With our training, mentorship, and career development programs, we’ll help you grow and succeed.

What Makes You a Great Fit:

• Strong clinical judgment and understanding of clinical documentation standards.
• Previous experience working in Clinical Documentation Integrity, provider documentation, coding, risk adjustment, or a similar role.
• Strong coding experience with a CC focus.
• Strong understanding of provider charting and clinical documentation practices.
• Detail-oriented with excellent organization and follow-through.
• Able to review complex medical information and organize supporting evidence.
• Comfortable working in the grey and making sound decisions when processes are still developing.
• Comfortable building structure, creating workflows, and helping establish best practices.
• Able to identify problems, develop solutions, and move work forward independently.
• Comfortable communicating with providers, clinical teams, and support staff.
• Able to provide neutral, professional, and non-leading documentation support.
• Strong coaching, education, and team development skills.
• Able to identify when an issue requires clinical, compliance, or leadership escalation.
• Comfortable working independently while collaborating with a multidisciplinary team.
• Strong computer and electronic medical record skills.
• CPR and First Aid Certification (or willingness to obtain after hire — we’ll provide the training!)

Education and Experience:

• Active, unrestricted Registered Nurse license in the applicable state.
• Minimum of 3 to 5 years of clinical nursing experience.
• Previous experience in Clinical Documentation Integrity, provider documentation, coding, risk adjustment, or a similar role required.
• Previous experience reviewing provider charts and clinical documentation required.
• Demonstrated coding experience with a CC focus required.
• Strong understanding of provider documentation and charting practices required.
• Experience working with older adults, medically complex Participants, chronic disease management, PACE, home-based care, or community-based care preferred.
• Experience reviewing electronic medical records and clinical documentation required.
• Experience providing training, coaching, quality review, or workflow oversight to Medical Assistants or other clinical support staff preferred.
• Experience with PACE, Medicare Advantage, value-based care, clinical documentation integrity, quality, audit, or risk adjustment is a plus.

Requirements:

• Ability to maintain confidentiality and protect sensitive Participant information.
• Ability to maintain a private and secure workspace when working remotely.
• Ability to work independently and manage priorities in a remote environment.
• Must be able to participate in virtual meetings and maintain consistent communication with providers, leadership, and clinical teams.
• Must be able to travel between centers or other locations as needed.
• Successful completion of required background checks, health and safety screenings, and any clearances required for healthcare programs.

Important Role Expectations:

• This position supports documentation integrity but does not replace the provider’s clinical judgment.
• The provider remains responsible for evaluating the Participant, determining clinical status, diagnosing, documenting medical decision-making, and signing the encounter.
• This position does not independently diagnose Participants or determine whether a condition should be submitted.
• This position does not select, assign, sequence, recommend, or submit ICD-10-CM, HCC, RAF, RAPS, or EDS diagnosis data.
• This position does not direct providers to document a specific diagnosis or code.
• Medical Assistants under this workflow are not authorized to interpret clinical evidence, determine condition status, create diagnoses, recommend codes or HCCs, or enter unsupported clinical information into the medical record.
• This position requires flexibility and comfort working in an evolving environment where processes may not always be fully established.
• The successful candidate will help build structure, develop workflows, identify opportunities, and establish best practices as the CDI program grows.

Physical Requirements:

• Must be able to sit and work at a computer for extended periods.
• Must be able to move intermittently throughout the workday.
• Must be able to remain focused and attentive while reviewing detailed clinical information.
• May be subject to frequent interruptions and changing priorities.
• Must be able to use standard office and computer equipment.
• Must be able to travel to centers and Participant care locations as required.

Join Us!

At One Senior Care, you’ll be part of a compassionate team that makes a tangible difference in seniors’ lives — working together to keep participants safe, healthy, connected, and at home.

One Senior Care is an Equal Opportunity Employer. Employment is contingent upon successful completion of required background checks, health and safety screenings, and any clearances required for healthcare programs.