Role Description The Clinical Documentation Specialist (CDS) is responsible for: - Distributing documentation information to respective departments. - Performing educational outreach to individual units and provider groups. - Supporting training of new staff members. - Designing and developing educational tools for staff and Providers. - Facilitating improvement in the overall quality and completeness of concurrent medical record documentation. - Helping achieve accurate inpatient coding, APR-DRG assignment, severity level, and reimbursement. - Functioning as subject matter liaison and leading documentation improvement initiatives. - Serving on internal hospital committees. - Obtaining appropriate documentation through interactions with physicians and collaboration with other departments. - Additional responsibilities as assigned. Shift/hours: Mon – Fri, 8:00am-5:00pm EST Location: 100% Remote (EST hours) Payrate: $60 hourly Qualifications - Baccalaureate degree, or associates degree, or diploma in nursing from an accredited school of Nursing OR successful completion of an AMA approved Physician Assistant program OR successful completion of the academic requirements of Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) certification accredited by CAHIIM. - Active RN License. - EPIC experience. - 12 months current RN experience in a similar role in MD or nationally using MSDRG. - Medicare Coding regulations 2024. - Minimum of 3 years Registered Nurse clinical experience in a similarly complex acute care setting. - Minimum of 2 years as a Clinical Documentation Specialist required. - In lieu of complex acute care experience, a minimum of 3 years of CDI experience and/or other relevant clinical experience may be considered. Requirements - Comprehensive knowledge of anatomy, physiology, and all body systems. - Strong background knowledge of disease processes and pharmacology. - College-level knowledge of Medical Terminology. - Complete understanding of the unique functions of each clinical area. - In-depth knowledge of clinical coding processing and documentation standards, guidelines, policies, and procedures. - Conversant in clinical documentation improvement. - High level of proficiency in adult education and training. - Thorough understanding of Hospital bylaws and Joint Commission standards. - Proficiency in abstraction and data entry into all database systems used for clinical documentation. - Ability to read and interpret electronic and manual documentation generated by healthcare professionals. - Understanding of HSCRC, Maryland Quality Improvement Programs, and CMI impact on hospital budget. - Knowledge of Healthcare Insurance Portability and Accountability Act (HIPAA). Skills - Conversant in ICD-10-CM, APRDRGs, DRGs. - Strong interpersonal and communication skills (verbal, non-verbal, and listening). - Understanding of adult learning theory, instructional design, and critical thinking. - Competent level with Microsoft Office Suite, web-browsers, email, electronic health records, online collaboration software, and virtual meeting applications. - Ability to work in a dynamic, team-oriented environment. - Ability to work independently and be self-directed. - Ability to work under pressure to meet submission, project, and reporting deadlines. - Ability to work in a fast-paced academic teaching hospital. Company Description Johns Hopkins Intrastaff is the internal staffing agency for the Johns Hopkins Health System and partner hospitals, providing temporary support to a variety of the Johns Hopkins locations. Our employees are the strength of our service. Intrastaff is unique because it's one of the very few agencies where a person has the benefit of being a temporary employee and also feels like a member of a large organization. Working at Hopkins means joining a culturally diverse team that includes some of the best nurses, physicians, and allied health professionals in the world. Directly or indirectly, you'll have exposure to cutting-edge technology and groundbreaking medical research.

• Provide education to providers and clinicians for accurate clinical documentation • Review for correct DRG, APC, and HCC assignment • Adhere to industry standards for documentation and coding compliance • Maintain a record of review and query activity in CDI software • Conduct reviews of medical records in outpatient settings • Educate providers on optimal documentation and coding

Title: Clinical RN Document Specialist Remote Location: Saint Alphonsus Regional Medical Center - Boise, Idaho Job Description: Employment Type: Full time Shift: Day Shift Description: GENERAL SUMMARY AND PURPOSE: The fully remote, RN Clinical Documentation Specialist is responsible for reviewing medical records to facilitate the accurate representation of thepatient'sseverity of illnessand risk of mortalityby improving the quality of the physician's clinical documentation. This involves extensive record review, interaction with physicians, Health Information Management (HIM) professionals, and nursing staff. Active participation in team meetings and education ofmedical, nursing, and ancillary staffis a key role. REQUIREMENTS: - Clinical License Required - RN or PA. Registered Nurse strongly desired. Proof of RN license is needed only in state of residence.BSN preferred. - CCDS, CDIPcertification a plus. - 3 to 5 years varied hospital clinical experience required. Critical care or strong medical surgical background preferred. - Ability to pass written clinical competency exam. WHAT YOU WILL DO: - Knows, understands, incorporates, and demonstrates the Organization's Mission, Vision, and Values in behaviors, practices, and decisions. - Ability to quickly learn and develop the skills necessary to performthe CDS role, including ability to accurately input relevant data into3M 360 Encompass and Cerner PowerChart(special purpose software). - Ensurephysician documentation contains adequate indicators to support the coding of diagnoses representative of eachpatient. - Able to audit for accuracy in a timely manner and follow up on all cases quickly, especially those with clarifications. - Formulates credibleand compliantclarifications to improve clinical documentation of principle diagnosis, co-morbidities,evidence of indicators representing conditionspresent on admission (POA), and quality core measures. - Facilitates modifications to clinical documentationof the medical recordthrough extensive interaction with physicians, nurses, and ancillary staff. - Developsand implement plans of education of physicians, nursing, and ancillary staff on documentation improvement. - Reviews inpatient medical records forallpayer populations on admissions andthroughouthospitalization. - Analyzes clinical information to identify areas within the chart for potential gaps in physician documentation. - Able to communicateeffectively and appropriately with individuals at all levels of the organization. - Actively participate in cross functional Task Force meetings. - Works collaboratively with the coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care.Able to effectively communicate with HIM staff and resolve discrepancies. - Responsible for completing all annual regulatory compliance education, as well as CDS-specific assigned education. - Understand and support compliant documentation strategies. - Knowledge of pathophysiology and disease process. - Knowledge of regulatory environment essential; knowledge of Medicare Part A and Part B is preferred. - Excellent organizational, analytical, and writing skills. - Ability to demonstrate critical thinking, problem solving and excellent interpersonal skills. - Excellent time management skills and the ability to manage multiple priorities effectively. - Dependable and self-directed. Saint Alphonsus and Trinity Health are committed to promoting diversity in its workforce and to providing an inclusive work environment where everyone is treated with fairness, dignity and respect. We are committed to recruit and retain a diverse staff reflective of the communities we serve. Saint Alphonsus and Trinity Health are equal opportunity employers and prohibit discrimination against any individual with regard to race, color, religion, gender, marital status, national origin, age, disability, sexual orientation, or any other characteristic protected by law. Colleagues of Saint Alphonsus Health System enjoy competitive compensation with a full benefits package and opportunity for growth throughout SAHS and Trinity Health. Visit www.saintalphonsus.org/careers to learn more about the benefits, culture and career development opportunities available to you at Saint Alphonsus Health System. Saint Alphonsus and Trinity Health are committed to promoting diversity in its workforce and to providing an inclusive work environment where everyone is treated with fairness, dignity and respect. We are committed to recruit and retain a diverse staff reflective of the communities we serve. Saint Alphonsus and Trinity Health are equal opportunity employers and prohibit discrimination against any individual with regard to race, color, religion, gender, marital status, national origin, age, disability, sexual orientation, or any other characteristic protected by law. Our Commitment Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Role Description The Clinical Documentation Improvement Specialist is responsible for facilitating the improved quality, accuracy and completeness of medical record documentation. This position will implement proactive measures to improve data quality, appropriate risk stratification of HCN’s VBS population and overall improvement in quality of care. - Serves as a subject matter expert on ICD-10-CM coding guidelines, AHA Coding Clinic Guidance and Risk Adjustment guidance. - Conducts proactive review of the medical record documentation including diagnosis coding, identification of co-morbidities and complications, and all appropriate secondary diagnoses. - Identifies issues and trends in coding and documentation that affect patient risk scores. - Works collaboratively with contracted health plans on risk adjustment initiatives; participates in auditing requests, reviews and assesses health plan results, and designs performance improvement plans as needed. - Develops and delivers provider and coder trainings, detailing coding best practices and provider level opportunities for improvement. - Provides education to providers, supporting clinical care teams, and coders on documentation, coding changes, compliance issues. - Advises and participates in VBS clinical quality, data analytics and RCM strategic initiatives. - Assists in the development and maintenance of coding educational tools. - Monitors changes in laws, regulations, rules, and code assignments that impact documentation and reimbursement. - Performs other duties as assigned. Qualifications - Education: Associate’s degree required; bachelor’s degree preferred. - Licensure: Current RN license in good standing preferred. - Experience: 5+ years of clinical experience, preferably in an FQHC primary care setting; 3+ years of experience in Medicare/Medicaid risk adjustment (HHS-HCC, CMS-HCC, or DxCG methodologies). - Certifications: Certified Risk Coder (CRC) through AAPC or CDI/CCS certification through AHIMA required; Certified Professional Coder (CPC) through AAPC preferred. - Technical Skills: Experience with the Epic Electronic Medical Records (EMR) system, preferred. Requirements - Experience ICD-10 coding with strong attention to detail and high accuracy rate. - In-depth knowledge of medical terminology, anatomy, physiology, and disease process. - Expertise in Medicaid and or Medicare risk adjustment models, HCC Coding required. - Working knowledge of health plan/insurance terminology and concepts. - Proficient with Microsoft Office products (Word, Outlook, Excel, PowerPoint). - Strong organizational and prioritization skills. - Excellent oral and written communication skills adaptable to individuals with varied levels of understanding at all levels of the organization. - Highly developed problem solving and deductive reasoning skills. - Must be able to handle multiple tasks at the same time and work well independently. Benefits - 100% Remote Work – Work from anywhere in the U.S. - 100% Employer-Paid Medical Insurance. - Annual $1,500 HSA Contribution. - Generous Paid Time Off (PTO). - 403(b) Retirement Plan with Employer Contribution. - Professional Development & Education Assistance. - Mission-driven culture focused on community health.