Nurse – Clinical Documentation Integrity, PACE

🔥 0 minutes ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

👻 Ghost score 12%

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One Senior Care

WebsiteLinkedInAll Job Openings

201 - 500 employees

🏥 Healthcare

📦 Logistics

💼 Consulting

Healthcare • Logistics • Consulting

One Senior Care is dedicated to enhancing the quality of life for seniors, particularly those in rural and underserved areas, by providing comprehensive, person-centered healthcare and social services. Their mission focuses on supporting PACE programs through innovative solutions and exceptional service, allowing caregivers to concentrate on offering quality care while minimizing administrative burdens. One Senior Care fosters partnerships among PACE community leaders to collaborate on best practices, share resources, and improve care outcomes for seniors, ultimately enabling them to live independently in their homes.

📋 Description

• Review existing medical records and approved clinical intelligence reports to identify documentation opportunities for provider review • Review provider notes, hospital, emergency department, and skilled nursing records, specialist documentation, medication profiles, labs, imaging, assessments, care plans, and prior documentation • Apply clinical documentation and coding knowledge, including CC-focused coding experience, when reviewing documentation opportunities • Identify documentation gaps related to condition status, specificity, acuity, chronicity, complications, treatment, monitoring, and assessment or plan clarity • Prepare concise, neutral clinical summaries for provider review • Present supporting evidence by date, location, and document type without directing the provider to a specific diagnosis or code • Support provider workflow during annual, semiannual, high-risk, complex care, and post-discharge visits • Facilitate appropriate non-leading clarification when documentation is incomplete, inconsistent, or unclear • Provide education to providers and clinical teams regarding documentation completeness, specificity, provider charting, and audit readiness • Monitor documentation trends, recurring gaps, and opportunities for improvement • Participate in quality reviews, compliance reviews, and audit-readiness activities • Collaborate with coding, risk adjustment, compliance, clinical leadership, and provider teams to improve documentation workflows • Provide functional oversight and guidance to Medical Assistants supporting documentation preparation • Help build and refine standardized workflows, work queues, templates, prioritization criteria, and turnaround expectations • Provide onboarding, training, competency validation, coaching, and feedback to Medical Assistants • Review samples of MA-prepared documentation for accuracy, completeness, neutrality, organization, and timeliness • Monitor documentation preparation workload, completion rates, rework, quality findings, and barriers • Help identify opportunities to improve and expand the CDI program • Work collaboratively with leadership to establish best practices, processes, and standards • Escalate privacy concerns, unsupported documentation, non-neutral language, or compliance concerns through established channels • Participate in quality improvement initiatives and ongoing training • Maintain confidentiality and a private, secure remote workspace • Participate in virtual meetings and maintain consistent communication with providers, leadership, and clinical teams • Travel between centers or other locations as needed • Do not independently diagnose Participants or select, assign, sequence, recommend, or submit diagnosis data • Help build structure, develop workflows, identify opportunities, and establish best practices as the CDI program grows

🎯 Requirements

• Active, unrestricted Registered Nurse license in the applicable state • Minimum of 3 to 5 years of clinical nursing experience • Previous experience in Clinical Documentation Integrity, provider documentation, coding, risk adjustment, or a similar role required • Previous experience reviewing provider charts and clinical documentation required • Demonstrated coding experience with a CC focus required • Strong understanding of provider documentation and charting practices required • Experience reviewing electronic medical records and clinical documentation required • Strong clinical judgment and understanding of clinical documentation standards • Strong understanding of provider charting and clinical documentation practices • Strong computer and electronic medical record skills • CPR and First Aid Certification (or willingness to obtain after hire — training provided) • Experience working with older adults, medically complex Participants, chronic disease management, PACE, home-based care, or community-based care preferred • Experience providing training, coaching, quality review, or workflow oversight to Medical Assistants or other clinical support staff preferred • Experience with PACE, Medicare Advantage, value-based care, clinical documentation integrity, quality, audit, or risk adjustment is a plus • Ability to maintain confidentiality and protect sensitive Participant information • Ability to maintain a private and secure workspace when working remotely • Ability to work independently and manage priorities in a remote environment • Must be able to participate in virtual meetings and maintain consistent communication with providers, leadership, and clinical teams • Must be able to travel between centers or other locations as needed • Successful completion of required background checks, health and safety screenings, and any clearances required for healthcare programs • Must be able to sit and work at a computer for extended periods • Must be able to move intermittently throughout the workday • Must be able to remain focused and attentive while reviewing detailed clinical information • Must be able to use standard office and computer equipment

🏖️ Benefits

• 9 Paid Holidays • PTO starting at 3 weeks + 1 day per year (accrued from date of hire for full-time employees) • Medical, Dental, & Vision • Free Life and AD&D Insurance Plan • Health Savings and Flexible Spending Accounts • Short Term Disability Insurance • Group Voluntary Term Life Insurance for Employee, Spouses, and Dependents • Paid Parental Leave • Tuition Reimbursement and Paid Training Opportunities • Retirement Plan with company annual match • Mileage Reimbursement at annual IRS rate as applicable • Training, mentorship, and career development programs