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Job Description:

The Clinical Documentation Integrity Nurse (CDI RN) utilizes clinical expertise, expert coding knowledge, and critical thinking skills to work collaboratively with Medical Directors. This position provides high-level expertise in the areas of coding and contracting, insurance regulations, and risk adjustment capitated revenue. Nurses review complex clinical provider notes and communicate with providers to meticulously identify ambiguous documentation or discrepancies between documentation and the patient's clinical presentation. This position also provides education and training to customers (physicians, mid-level providers, office staff) on clinical indicators and risk adjustment capitated revenue.

+ 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. Maintain thorough clinical knowledge of disease processes, pathophysiology, and pharmacology.

+ 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.

Skills

+ Clinical Knowledge

+ Chart Review Accuracy

+ Critical Thinking

+ Educational Leadership

+ Data Analysis

+ ICD -10 Coding

+ Clinical Communication & Coordination

+ Clinical Documentation Integrity

+ Health Care Compliance

Minimum Qualifications

+ 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

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.

Physical Requirements:

+ Ongoing need for employees to see and read information, labels, assess patient needs, operate monitors, identify equipment and supplies.

+ Frequent interactions with patient care providers, patients, and visitors that require employees to verbally communicate as well as hear and understand spoken information, alarms, needs, and issues quickly and accurately, particularly during emergency situations.

+ Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use and typing for documenting patient care, accessing needed information, medication preparation, etc.

+ Expected to lift and utilize full range of movement to transfer patients. Will also bend to retrieve, lift, and carry supplies and equipment. Typically includes items of varying weights, up to and including heavy items.

+ Need to walk and assist with transporting/ambulating patients and obtaining and distributing supplies and equipment. This includes pushing/pulling gurneys and portable equipment, including heavy items. Often required to navigate crowded and busy rooms (full of equipment, power cords on the floor, etc.)

+ May be expected to stand in a stationary position for an extended period of time.

+ For roles requiring driving: Expected to drive a vehicle which requires sitting, seeing and reading signs, traffic signals, and other vehicles.

Location:

Nevada Central Office

Work City:

Las Vegas

Work State:

Nevada

Scheduled Weekly Hours:

40

The hourly range for this position is listed below. Actual hourly rate dependent upon experience.

$43.98 - $63.79

We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.

Learn more about our comprehensive benefits package here (https://intermountainhealthcare.org/careers/benefits) .

Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

At Intermountain Health, we use the artificial intelligence ("AI") platform, HiredScore to improve your job application experience. HiredScore helps match your skills and experiences to the best jobs for you. While HiredScore assists in reviewing applications, all final decisions are made by Intermountain personnel to ensure fairness. We protect your privacy and follow strict data protection rules. Your information is safe and used only for recruitment. Thank you for considering a career with us and experiencing our AI-enhanced recruitment process.

All positions subject to close without notice.