Role Description Join Fairview as a Clinical Documentation Integrity Specialist and play a key role in ensuring accurate, complete, and compliant inpatient medical record documentation. In this fully remote position, you'll collaborate with physicians, coders, and clinical teams to: - Review patient records - Identify documentation improvement opportunities - Support accurate DRG assignment - Enhance quality outcomes, regulatory compliance, and reimbursement This role is ideal for an experienced RN, RHIA, or RHIT professional with a strong understanding of clinical documentation, coding, and inpatient care. You'll use your analytical skills and clinical expertise to drive documentation excellence while educating providers and contributing to continuous improvement initiatives. Qualifications - Associates Degree in Nursing or Health Information Management (HIM) degree or related field or equivalent experience - 2 years Acute/Inpatient experience as an RN or 5 years inpatient coding experience - Knowledge of clinical documentation requirements related to regulatory and reimbursement rules and regulations - Knowledge of current coding and DRG classification systems - Knowledge of medical terminology, anatomy and pathophysiology, pharmacology, ancillary test results - Knowledge of ICD-10-CM and DRG classification systems - Knowledge of physician and nursing unit practices - Excellent interpersonal, critical thinking and conflict management skills - Computer and data analysis skills - Excellent verbal and written communication and presentation skills - Analytical Thinking: Ability to identify issues, obtain relevant information, relate and compare data from different sources and identify alternative solutions - Attention to detail: Achieve thoroughness and accuracy when accomplishing a task - Critical Thinking: Gathers and integrates critical information, recognizing and addressing underlying assumptions of others to arrive at effective solutions - Medical Staff Relations: Builds effective partnerships with medical staff, physicians, fostering open lines of communications and establishing trust - Problem Solving: Identifies problems, determines accuracy and relevance of information, utilizes appropriate tools and staff resources along with sound judgment to generate and evaluate alternatives and to make recommendations - Written Communication: Ability to organize and express information and ideas in written form to individuals as well as groups. Constructs messages that are clear and convincing - Registered Nurse of MN Upon Hire or current Registered Health Information Administrator (RHIA) MN Board of Nursing or American Health Information Management Association Upon Hire or Registered Health Information Tech (RHIT) MN Board of Nursing or American Health Information Management Association Upon Hire Requirements - 5 years acute care nursing or 5 years inpatient coding experience (preferred) - Bachelors Degree in Nursing for candidates with nursing experience (preferred) - Certified Clinical Documentation Specialist (CCDS) for candidates with HIM experience American Health Information Management Association Upon Hire (preferred) Benefits - Generous benefit package including medical, dental, vision plans - Life insurance - Short-term and long-term disability insurance - PTO and Sick and Safe Time - Tuition reimbursement - Retirement - Early access to earned wages - And more! Company Description Fairview offers a collaborative, mission-driven healthcare environment with an opportunity to influence patient care quality and organizational outcomes.

• Oversee medical writing workstreams, ensuring deliverables meet quality and timeline expectations • Lead the preparation and review of clinical study reports, protocols, and other regulatory documents to ensure accuracy and clarity • Collaborate with cross-functional teams, including clinical research, biostatistics, and regulatory affairs, to gather and synthesize information for document development • Provide guidance on best practices for medical writing and ensure adherence to regulatory requirements and internal standards • Mentor and train junior medical writers, fostering a culture of excellence and professional growth • Stay current with industry trends and regulatory guidelines to inform writing practices and maintain high-quality outputs • Act as a lead medical writer for complex projects and lead clinical/regulatory marketing approval applications for new biologics and drugs

• Translate complex benefit information, including non-standard plan language into crisp, compliant, easy-to-understand plan language for self-funded plans • Analyze, draft, edit and review all legal and regulatory plan documentation for self-funded plan customers • Ensure the plan and company remain in compliance with federal and state law • Deliver high-quality documentation ensuring department standards are met

Role Description The Lead Clinical Documentation Department Improvement Specialist is a certified coder with a high level of clinical proficiency necessary for leadership of the Clinical Documentation team of licensed nurses and certified coders. Oversees the review processes of complex pediatric patients in accordance with all current payer initiatives and development in acute and chronic disease states. - Understands a wide range of specialized disciplines, including education in anatomy and physiology, pathophysiology, and pharmacology. - Knowledge of official medical coding guidelines, CMS, and private payer regulations related to the Inpatient Prospective Payment System. - Ability to analyze and interpret medical record documentation and formulate appropriate physician queries. - Ability to benchmark and assist in analyzing clinical documentation program performance. - Exhibits sufficient knowledge of clinical documentation, coding, reporting requirements, APR-DRG assignment, and clinical conditions or procedures impacting severity of illness, risk of mortality, and/or data quality. - Facilitates complete and accurate documentation and coding of inpatient medical records on a concurrent and retrospective basis. - Serves as a resource for HIM coders and physicians regarding proper documentation practices and the link to ICD-10 codes and APR-DRG assignments. - Collaborates with interdisciplinary teams including physicians, nurse practitioners, PA's, Quality, Case Management, Risk Management, Health Information Management/Coding, Decision Support, product vendors, and other members of the health care team. - Involved in the direction and education of all phases of the Clinical Documentation process. - Requires knowledge and leadership of the day-to-day processes of the Clinical Documentation team including workflow and training needs. - Assists management with providing ongoing Clinical Documentation education for current and new staff. - Maintains professional development by participating in workshops, conferences, and/or in-services. Qualifications - Must maintain current knowledge of reimbursement systems and federal, state and payer-specific regulations and policies. - Must demonstrate continuing education in CDI, inpatient coding, and/or reporting compliance areas. - Certificates, Licenses, Registrations: RHIA, RHIT, or CCS certification preferred or eligible – to be achieved within 2 years of employment. - CDIP or CCDS certification preferred or eligible – to be achieved within 3 years of employment. Requirements - Always maintains utmost level of confidentiality and integrity. - Adheres to hospital policies and procedures. - Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines. - Serves as a subject matter expert for the CDI program, inpatient coding, and reimbursement methodologies. - Demonstrates ability to educate medical and hospital staff regarding the MS-DRG and APR-DRG reimbursement methodologies. - Assists HIM management with coordination of CDI compliance reviews. - Communicates with hospital personnel regarding questions relevant to CDI, inpatient coding, and reimbursement. - Assists HIM management in communicating with physicians and other clinicians concerning opportunities for improvement relevant to clinical documentation and its impact on reporting. - Assists HIM management in the development and maintenance of hospital specific CDI, reporting and billing guidelines. - Attends hospital committee meetings as needed. - Monitors and evaluates case mix patterns and trends. - Reviews and codes inpatient medical records as needed for additional backlog and reporting support. - Assists with special projects as assigned by HIM management. - Completes initial reviews timely in order to promptly identify potential documentation improvement opportunities. - Conducts follow-up reviews of patients as scheduled to support and assign a working or final APR-DRG. - Queries physicians regarding missing, unclear, or conflicting health record documentation. - Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record. - Collaborates with CDI Physician Champion, case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge. - Participates in the analysis and trending of statistical data for specified patient populations to identify documentation improvement opportunities. - Assists with preparation and presentation of clinical documentation monitoring/trending reports for review. - Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to assign ICD-9-CM and ICD-10-CM/PCS diagnosis and procedure codes to determine an accurate working and final APR-DRG, severity of illness, and/or risk of mortality. - Assists in the appeal process resulting from third-party reviews. - Proficiency in the use of Microsoft applications (e.g. Word, Excel, PowerPoint), Epic, and 3M CRS and 3M CDI 360 Encompass. Benefits