Remote Clinical Documentation Improvement Nurse - Certified

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Position Summary

As a member of the GA Programs team, the Clinical Documentation Improvement Nurse partners key stakeholders within the health plan, delivery systems, and provider network to develop and implement processes and best practices to support accurate diagnostic coding and attention to gaps in care as it relates to Medicare Advantage Risk Adjustment. This role is also responsible for reviewing clinical documentation to support HEDIS, and to participate in the HEDIS medical record abstraction process. The Clinical Documentation Improvement Nurse is responsible in assisting the provider community to improve the overall accuracy, quality and completeness of clinical documentation.

Job Description

Key Outcomes:

• Facilitates recommendations for improvement to clinical documentation through extensive interaction with key stakeholders in the delivery system and participating provider network to ensure the accuracy of the documentation and coding reflective of the reviewed services rendered.
• Ensures the accuracy and completeness of clinical information used for measuring and reporting outcomes and confirms accuracy of diagnosis codes on submissions to the Centers for Medicare and Medicaid Services (CMS).
• Provides education as it relates to quality and risk adjustment documentation and reporting in the delivery system, and participating provider network
• Identifies trends, develops and executes action plans to increase clinical documentation accuracy and capturing of risk adjustable codes
• Supports accreditation and regulatory compliance by evaluating process effectiveness, identifying and acting on improvement opportunities, and ensuring that all HEDIS requirements are met
• Ensures compliance for all HEDIS quality audits and maintain all data and process controls
• Manages internal and external relationships to promote positive working relationships and advancement of HEDIS and Risk Adjustment clinical documentation and coding reporting initiatives
• Serves as risk adjustment coding subject matter expert from a clinical perspective and works collaboratively with management team to strategically plan and execute risk adjustment coding efforts to yield desired outcomes
• Research and understand CMS and other regulatory and reputable risk adjustment publications to assist in development of best practice policies and creation of educational materials such as coding newsletters for distribution to providers with the most up to date guidelines and changes. Ensures the completeness and accuracy of the clinical documentation by reviewing clinical records, identifying gaps or inaccuracies, formulating credible clarifications and communicating with providers to clarify clinical diagnoses, ICD 10 code selections and supporting documentation.
• Provides training to providers, practice leadership and designated staff to facilitate accuracy of clinical documentation and risk adjustment coding and to improve methodologies to support data integrity.
• Reviews clinical documentation, identifies incomplete or inaccurate information for clinical relevance. Works with key stakeholders in a timely manner to ensure points of clarification are recorded in medical records.
• Keep abreast of Medicare Advantage program and how it impacts payment, knowledge of pathophysiology and disease process.
• Knowledge of value-based purchasing and other quality metrics affecting the clinical documentation integrity program.
• Reviews and analyzes population data and metrics to inform improved coding outcomes
• Identifies gaps in clinical operational structure between current and desired state
• Develop monitoring tools to track successes and challenges in the CDI program in order to facilitate process improvements
• Performs all other related duties as assigned

Education/Experience:

• Bachelor’s Degree in Nursing required
• Current RN license in good standing required
• 5+ years’ clinical experience, preferably in geriatrics
• 2 years of clinical coding experience with strong attention to detail and a high level of accuracy preferred
• Ability to speak and provide presentations and education to small and large groups alike
• Ability to work a flexible work schedule and willingness to travel (locally) as determined by business need
• One or more of the following Licenses/Certifications required: CDI, CPC, CPC-H, CPC-P, CRC, CCS, CCS-P, CPMA

Skills/Knowledge/Competencies (Behaviors):

• Knowledge of HEDIS, abstraction concepts, Medicare Risk Adjustment preferred
• Ability to assess population health needs and define health improvement priorities
• Excellent verbal and written communication skills required
• Self-motivated and accountable for project coordination and follow-through
• Strong organizational and planning skills required
• Must meet deadlines and produce accurate work product
• Must be able to handle multiple tasks at the same time
• Must work well independently
• Maintain strong clinical knowledge and understanding of Evidenced-Based Practice principles
• Define and educate regarding appropriate sources for standards of care
• Ability to review and analyze population data and metrics to inform development of programs
• Create, build and maintain relationships in order to improve performance and establish trust and maintain creditability throughout the organization
• Impact and influence: ability to make a difference
• Demonstrate adaptability and flexibility in the face of changing demands.
• Demonstrate willingness to perform additional tasks as assigned
• Display initiative to improve relative to job function.
• Contribute ideas to help improve processes and abstracting data
• Demonstrate an understanding of and alignment with Martin’s Point Values.

Pay Range: $86,926.10 - $107,379.30 The pay range above reflects the anticipated base pay range based on a full-time position. Actual compensation will be determined based on factors such as experience, skills, qualifications, and other job-related considerations. Employees may also be eligible for additional compensation, including incentive or commission-based programs, where applicable and subject to the terms of the relevant plan. In addition to base compensation, we offer a comprehensive benefits package including medical, dental, vision, retirement savings with employer contributions, paid time off (including volunteer time off!), pie day, and other employee benefits.

This position is not eligible for immigration sponsorship.

We are an equal opportunity/affirmative action employer.

Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact View email address on us.fitly.work

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