Clinical Documentation Specialist

Location: Remote

Facility: Ascension Wisconsin Hospitals

Department/Specialty: Clinical Integrity Documentation

Schedule: Days | Full-time

Salary Range: $75,295.00-$104,957.00

• Drive improvement in the overall quality, completeness, and accuracy of medical record documentation.
• Conduct admission reviews, assign a working Diagnosis Related Group (DRG), and ensure the working DRG and other pertinent data are accurately logged in the Clinical Documentation Improvement (CDI) database.
• Initiate and sustain comprehensive communication with physicians and mid-level providers to procure more detailed information for the medical record.
• Collaborate with other healthcare professionals to guarantee that the severity of illness and the level of services rendered are precisely reflected in the medical record. This includes resolving physician queries and documentation discrepancies prior to patient discharge.
• Maintain meticulous records of all review activities, validating the accuracy of reports and outcomes generated from CDI efforts.

Licensure / Certification / Registration:

• One or more of the following required:
  
  • Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
  • Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
  • Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
  • Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.
  • Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
  • Registered Nurse credentialed from the Wisconsin Board of Nursing obtained prior to hire date or job transfer date. Licensure from the Wisconsin Board of Nursing OR current home state license if considered multi-state/Compact State.

Education:

• High School diploma equivalency with 2 years of cumulative experience OR Associate's
  degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.

• 5 or more years of nursing experience in ICU and/or Emergency Department
• Previous Clinical Documentation Specialist experience

Ascension is a leading nonprofit Catholic health system with a culture and associate experience grounded in service, growth, care and connection. We empower our 99,000+ associates to bring their skills and expertise every day to reimagining healthcare, together. Recognized as one of the Best 150+ Places to Work in Healthcare and a Military-Friendly Gold Employer, you’ll find an inclusive and supportive environment where your contributions truly matter.

Equal employment opportunity employer

Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws. For further information, view the EEO Know Your Rights (English) poster or EEO Know Your Rights (Spanish) poster.

Fraud prevention notice

Prospective applicants should be vigilant against fraudulent job offers and interview requests. Scammers may use sophisticated tactics to impersonate Ascension employees. To ensure your safety, please remember: Ascension will never ask for payment or to provide banking or financial information as part of the job application or hiring process. Our legitimate email communications will always come from an @ascension.org email address; do not trust other domains, and an official offer will only be extended to candidates who have completed a job application through our authorized applicant tracking system.

E-Verify statement

Employer does not participate in E-Verify and therefore cannot employ STEM OPT candidates.

Paid time off (PTO)
Various health insurance options & wellness plans
Retirement benefits including employer match plans
Long-term & short-term disability
Employee assistance programs (EAP)
Parental leave & adoption assistance
Tuition reimbursement
Ways to give back to your community

Benefit options and eligibility vary by position. Compensation varies based on factors including, but not limited to, experience, skills, education, performance, location and salary range at the time of the offer.