RN Clinical Documentation Specialist

Pathways Hospice

$80K — $94K *
Healthcare
5 - 7 years of experience
Job Overview by Ladders

Qualifications

  • Graduate of an accredited nursing school
  • 5 years' experience in hospice or home health medical record review
  • 2 years' experience with electronic health records (EHRs) and auditing software
  • Proficient with Microsoft Office suite
  • Excellent written and verbal communication skills
  • Strong analytical and critical-thinking skills
  • Current Colorado RN license or equivalent licensed state, OASIS D and ICD-10 certification preferred

Responsibilities

  • Review patient medical records for clinical, regulatory, and billing compliance
  • Conduct thorough documentation reviews within 24-48 hours of admission
  • Identify and clarify missing or vague documentation with providers
  • Ensure records adhere to federal and state regulations, including CMS and HIPAA
  • Analyze audit findings and present quality reports to staff
  • Educate staff on documentation procedures and compliance best practices
  • Assist with internal and external audit preparations

Benefits

  • Full-time Monday-Friday schedule, 8-5
  • Supplemental pay options including stipends and mileage reimbursement
  • High mileage reimbursement rate of 62.5 cents per mile
  • Opportunities for professional development through education offerings
  • Supportive work environment focused on continuous improvement
  • Involvement in compliance and regulatory practices of the hospice care industry
Full Job Description
The Denver Hospice has an opening for an RN Clinical Documentation Specialist.

Location: Denver, CO

Status: Full-time

Schedule: Monday-Friday, 8-5

Pay Range: $80,288 - $94,328 annually

Supplemental Pay: Based on position, schedule and/or availability: Stipends/Shift Diffs/Paid Mileage

Mileage and Expense Reimbursement: Sixty-two and a half cents per mile - one of the highest in the industry!

REWARDING WORK YOU WILL DO:

Responsible for reviewing patient medical records to ensure they meet clinical, regulatory, and billing compliance standards. This role combines clinical expertise with a deep understanding of healthcare regulations, including those from the Centers for Medicare and Medicaid Services (CMS).

  • Conducts thorough reviews of clinical documentation during the patients' stay, often within 24-48 hours of admission, such as patient charts, care plans, and physician's orders, to ensure they are complete, accurate, and support the patient's initial and ongoing eligibility for hospice services.
  • Identifies missing, vague, or conflicting documentation regarding a patient's condition and treatment and works closely with physicians and other providers to gain clarity or obtain additional information.
  • Verifies that all records and billing practices adhere to applicable federal and state regulations, including CMS and HIPAA standards.
  • Analyzes audit findings to identify trends and patterns in documentation quality. Generates quality reports and presents findings to clinical staff and leadership to facilitate continuous improvement.
  • Educates clinicians and other staff on proper documentation procedures, compliance essentials, and best practices. May help develop training materials for staff development.
  • Assists in preparing for internal and external audits, including those from regulatory bodies like the Office of Inspector General (OIG), Accreditation Commission for Health Care (ACHC) & Colorado Department of Public Health and Environment (CDPHE).
  • Ability to critically appraise hospice patient charts and determine if they are in compliance.
  • Translate audit findings and trends into organizational improvement activities.
  • Create and deliver educational offerings, team member coaching, etc., from chart findings to drive improvement.


WHAT WE ARE GOING TO LOVE ABOUT YOU:

  • Graduate of an accredited school of nursing.
  • 5 years' experience in hospice or home health medical record review, medical terminology, and relevant regulations, including Medicare and Medicaid rules is preferred.
  • 2 years' experience with electronic health records (EHRs) and auditing software is necessary. Proficiency with basic computer programs, including the Microsoft Office suite, is also required.
  • Excellent written and verbal communication skills are critical for reporting findings and providing feedback to staff.
  • Strong analytical and critical-thinking skills are needed to research complex coding and compliance issues.
  • Current Colorado RN license or a license from the state of primary residence, if participating in the NLC (Nurse Licensure Compact). OASIS D and ICD-10 certification is preferred but may be substituted for actual hands-on experience.


PHYSICAL REQUIREMENTS:

  • Ability to lift/carry a minimum of 30 lbs.


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