Professional Clinical Documentation Specialist

Everything we do is underscored by a why — and that why is one another.

Location:

Altru Health System
PO Box 6002
Grand Forks, ND 58201

Summary:

Essential Job Functions:

• Identifies opportunities to recapture previously documented HCC conditions and identify potential new or “suspect” conditions supported by appropriate clinical indicators and the patient’s medical record. These reviews support accurate patient risk profiles and associated healthcare resource utilization.
• Evaluates E/M encounters to identify opportunities related to medical decision-making, patient acuity, E/M level assignment, diagnosis capture, and HCC documentation.
• Delivers individualized and group education to providers based on findings from pre-visit and post-claim reviews, data analytics, provider performance trends, and identified documentation or coding opportunities.
• Collaborates with Professional Fee CDI leadership, CDI and coding teams, and other organizational partners to support program objectives, coordinate initiatives, and foster effective teamwork.
• Uses performance, outcome, and other available data to identify high-priority providers, specialties, encounter types, workflow opportunities, and educational needs.
• Supports the development, implementation, and evaluation of Professional Fee CDI workflows, processes, education schedules, and program initiatives.
• Identifies opportunities to clarify the medical record in a compliant and non-leading manner, consistent with applicable coding, documentation, query, regulatory, and organizational guidelines.
• Creates and delivers specialty-specific education and ongoing feedback based on chart review findings, data analytics, provider performance trends, and identified documentation or coding opportunities.
• Communicates effectively with providers, CDI team members, coding, compliance, and other stakeholders through individual consultations, provider meetings, department or specialty sessions, and other appropriate forums.
• Maintains current knowledge of CMS requirements, official coding guidelines, HCC models, risk adjustment principles, E/M guidelines, clinical documentation requirements, and applicable industry standards.
• Maintains confidentiality in accordance with HIPAA and applicable privacy and security requirements; follows organizational policies and procedures; demonstrates professionalism and respect in all interactions; and pursues ongoing professional growth and development.
• Performs other duties as assigned or needed to meet the needs of the department/organization.

Certifications

• Registered Nurse | North Dakota Board of Nursing (NDBON) or Compact State Agreement | Prior to Start Date | HR Primary Sources

Notes

• Must hold an unencumbered nursing license  prior to start.

Work Experience:

Language Requirements:

This position requires proficiency in reading, writing, and speaking English to ensure effective communication in the workplace and with patients, families, and team members.

Physical Demands :

Weight Demands:

Working Conditions:

Driving Requirement Definitions:

• Professional Drivers: Persons who drive as their main responsibility OR transport passengers or hazardous materials.
• Frequent Drivers: Persons whose main responsibility is not driving, but drive daily or almost daily.
• Occasional Drivers: Persons who drive from once per month to as frequently as once per week.
• Infrequent Drivers: Persons who are generally not expected to drive.

Driving Requirement for this position:

Making a real difference. For one another.

To take the best care of our patients and community — including friends, family, and neighbors — we need people who are committed to growth, excellence, and one another.

At Altru, you’ll find a culture where support and teamwork are at the heart of what we do. You’ll have opportunities to advance your skills, work with the latest technologies, experience the fulfillment that comes from giving back, and take your career wherever you want it to go.

Join our team and be a part of a small community with a big heart.

Altru offers a comprehensive benefits package to its full- and part-time employees. Excellent benefits include a health plan and 401(k) retirement plan. Other benefits include a dental plan, vision plan, life and disability insurance, education assistance, paid time off (PTO)

About Us

At Altru, everything we do is underscored by a why—and that why is one another.

We believe in the power of community and the difference we can make together. As the trusted healthcare provider in our region, we’re driven by a commitment to quality care and creating a supportive environment where every team member can thrive. Here, you’ll have opportunities to advance your skills, work with the latest technologies, and experience the fulfillment that comes from giving back—taking your career wherever you want it to go. Join our team and be part of a small community with a big heart.

Want a closer look at life at Altru? Follow us on our careers social channels to see our people, culture, and impact in action—and stay up to date on new opportunities.

• Facebook.com/AltruCareers
  
• Instagram.com/AltruCareers

Reasonable Accommodations

Altru provides reasonable accommodations to individuals with disabilities to increase opportunities and eliminate barriers to employment. If you need a reasonable accommodation in the application process to access job postings, to apply for a job, for a job interview, for pre-employment testing, or with the onboarding process, please contact Altru’s Human Resources Department at hrhelpdesk@altru.org or 701.780.5107.

Equal Opportunity

Altru is an Equal Opportunity Employer. Learn more or to request a copy of our Equal Employment Opportunity and Eligibility policy and Affirmative Action Plan at no charge, please contact Altru’s Human Resources Department at hrhelpdesk@altru.org or 701.780.5107. Additionally, the following poster is available through the Department of Labor: Know Your Rights.

Altru participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization.