Qualifications

• Bachelor's degree in nursing required
• Current Registered Nurse (RN) licensure in Minnesota required
• Minimum of 3 years acute care experience required
• Experience in performance improvement and quality assurance required
• Certified Clinical Documentation Specialist (CCDS) certification preferred
• CCDS-Outpatient certification preferred
• Experience in utilization review, coding, clinical informatics, case management, or critical care preferred
• Completion of ACDIS bootcamp or CDI Apprenticeship preferred
• Strong critical thinking skills needed to process and evaluate complex information.

Responsibilities

• Audit medical record documentation for quality and compliance
• Facilitate physician documentation for accurate representation of patient care
• Proactively seek clarification from clinical staff on documentation issues
• Consult with attending physicians on conflicting information in records
• Document and share audit results with staff and management
• Collect and analyze data to support process improvement initiatives
• Educate providers on disease processes and documentation best practices.

Benefits

• Medical and dental insurance
• Paid time off (PTO)
• Retirement plan
• Employee discounts
• Tuition reimbursement and college grant opportunities
• Remote work flexibility after training with occasional site travel.