Job Opportunities in United States

Love + medicine is who we are, it's what we do, it's why people want to work here. If you’re looking for a job to love, apply today.

Schedule Weekly Hours:
40
Gundersen Health System is looking for a full-time RN (1.0 FTE) to work as an Ambulatory Clinical Documentation Improvement Specialist in La Crosse, WI. This is your opportunity to do the work you love in the beautiful Coulee region.

What you will do:

• Work full-time (40 hours/week) in this salaried position

• Utilize your clinical expertise to identify and facilitate modification to quality and completeness of medical record documentation of medical and associate staff.

• After successful orientation on-site, this position will be a work-from-home position

What you will get:

• No work on weekends and holidays

• Top-rated retirement and healthcare benefits

• Support to grow your career with access to our Career Development Center and Tuition Investment Program

What you need:

• Bachelor’s Degree in Nursing

• 3 years of nursing experience in training/education

• 3 years of nursing experience, prefer ambulatory

• RN licensure in the state of Wisconsin upon hire

Gundersen Health System is healthcare for neighbors, by neighbors. While we call La Crosse home, our system has 7 hospitals and 65 clinics in neighboring communities. Inside our walls and our neighborhoods, we deliver world-class medical care combined with the right amount of love. We call it Love + Medicine and it’s who we are.

You may be asked to complete an on-demand video interview (powered by Hire Vue) as a first step in the process.

Job Description:

The RN- Ambulatory Clinical Documentation Specialist (CDS), working under the direction of the Supervisor, CDES and Ambulatory CDI and the physician leaders of the Clinical Documentation Improvement Services (CDIS), utilizes clinical expertise to identify and facilitate
modifications to quality and completeness of medical record documentation of medical and associate staff. Through evaluation and assimilation of the objective and subjective data documented in the medical record along with interactions with physicians, residents, and associate staff, the CDS will be responsible for educating providers to achieve improved documentation results for the organization. The outcome will be documentation that accurately and completely captures the clinical picture of the patient while providing accurate and complete information to be utilized in coding, profiling and outcomes reporting of both Gundersen Health and the Physicians. The CDS utilizes knowledge of national coding guidelines (ICD-10 CM), Hierarchical Condition Category (HCC) diagnoses, standards of compliance, and clinical expertise to identify opportunities and achieve results.

Major Responsibilities:
1. Demonstrates knowledge of documentation requirements and coding guidelines that recognize Hierarchical Condition Category (HCC) diagnosis capture and supporting documentation. Improves the overall quality and completeness of clinical documentation by performing systematic chart reviews.
2. Maintains daily workload such as but not limited to: scheduled Medicare Annual Wellness Visit (MAW), post MAW reviews, clarifications to Primary Care Physicians after MAW visit is completed, Epic workques, and tracking accounts.
3. Confers with medical and associate staff face-to-face or through standard clarification systems to facilitate modification of clinical documentation and to reinforce education regarding the significance of appropriate documentation. Serves as a resource to the professional staff, assuring compliance with all national coding guidelines and governmental regulations regarding physician documentation.
4. Achieves and maintains current knowledge and understanding of ICD-10 CM coding guidelines through participation in education and training, including reading and comprehension of AHA Coding Clinic.
5. In partnership with CDI team and CDI physician leaders, develops curriculum and delivers education to the medical staff, residents and other clinicians using a variety of teaching methods including regular rounding in outpatient clinics and small group presentations at department and section meetings.
6. Confers and collaborates with Coding Specialists/CDES to deepen their understanding of pathophysiology in support of accurate and compliant code assignment. Performance is consistent with the Code of Ethics of the American Health Information Management Association (AHIMA) and the Association of Clinical Documentation Improvement Specialists (ACDIS).
7. Develops and reports performance measures for the medical staff, Executive Committee and Administration.
8. Consistently utilizes monitoring tools to track the progress of the Clinical Documentation Improvement Program. Interprets monthly tracking reports of findings and identifies and acts on opportunities for improvement.
9. Assists service line directors, department chairs and section chiefs with documentation to improve risk-adjusted statistics, national profiles, and benchmarking.
10. Maintains flexibly, adjusting work time and availability to fulfill the program goals, achieve outcomes and meet the needs of the medical staff.
11. Maintains professionalism in conduct, attire and communication with clinicians, residents, associate staff, and peers.
12. Adheres to regular and predictable attendance.
13. Performs other job-related responsibilities as requested or assigned.

Education and Learning:
REQUIRED
Bachelor’s degree in Nursing

DESIRED
Bachelor's degree in Nursing and ICD Diagnosis and Procedure Coding Training demonstrated by certificate of completion.

Work Experience:
REQUIRED
3-4 years nursing experience with proven experience in training/education

DESIRED
5-7 years of nursing, preferred clinical nursing, including one year work experience in clinical documentation improvement or directly related experience.

License and Certifications:
REQUIRED
Registered Nurse (RN) licensed minimally in the state of practice, some positions may require additional state RN licenses.

DESIRED
Certified Coding Specialist (CCS) or Certified Clinical Documentation Specialist (CCDS) or Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) or Certified Coding Specialist - Physician Based (CCS-P) or American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) or any certification in coding or clinical documentation improvement.

Age Specific Population:
Nonage Specific (N/A)

Osha Category:
Category 3 - Employees in this job title have no reasonably anticipated risk of occupational exposure to blood and/or other potentially infectious materials.

Environmental Conditions: (Read through each description and delete what does not apply.)
Not substantially exposed to adverse environmental conditions (as in typical office work)

Physical Requirements/Demands of The Position:
Sitting Approximately 5.5 hours in a day (34-66%)
Walking/Standing Approximately 5.5 hours in a day (34-66%)

I f you need assistance with any portion of the application or have questions about the position, please contact HR-Recruitment@gundersenhealth.org or call 608-775-0267

We inspire your best life by relentlessly caring, learning and innovating. This is our purpose. Together with our values — belonging, respect, excellence, accountability, teamwork and humility — our pillars set our foundation and our future.

Equal Opportunity Employer