Inpatient Clinical Documentation Specialist RN
Billings Clinic

You'll want to join Billings Clinic for our outstanding quality of care, exciting environment, interesting cases from a vast geography, advanced technology and educational opportunities. We are in the top 1% of hospitals internationally for receiving Magnet® Recognition consecutively since 2006.

And you'll want to stay at Billings Clinic for the amazing teamwork, caring atmosphere, and a culture that values kindness, safety and courage. This is an incredible place to learn and grow. Billings, Montana, is a friendly, college community in the Rocky Mountains with great schools and abundant family activities. Amazing outdoor recreation is just minutes from home. Four seasons of sunshine!

You can make a difference here.

About Us
Billings Clinic is a community-owned, not-for-profit, Physician-led health system based in Billings with more than 4,700 employees, including over 550 physicians and non-physician providers. Our integrated organization consists of a multi-specialty group practice and a 304-bed hospital. Learn more about Billings Clinic (our organization, history, mission, leadership and regional locations) and how we are recognized nationally for our exceptional quality.

Your Benefits
We provide a comprehensive and competitive benefits package to all full-time employees (minimum of 24 hours/week), including Medical, Dental, Vision, 403(b) Retirement Plan with employer matching, Defined Contribution Pension Plan, Paid Time Off, employee wellness program, and much more. Click here for more information or download the Employee Benefits Guide.

Magnet: Commitment to Nursing Excellence
Billings Clinic is proud to be recognized for nursing excellence as a Magnet®-designated organization, joining only 97 other organizations worldwide that have achieved this honor four times. The re-designation process happens every four years. Click here to learn more!

Pre-Employment Requirements
All new employees must complete several pre-employment requirements prior to starting. Click here to learn more!

Inpatient Clinical Documentation Specialist RN
FINANCE (Billings Clinic Main Campus)
req8914

Shift: Day, Weekends
Employment Status: Full-Time (.75 or greater)
Hours per Pay Period: 1.00 = 80 hours (Non-Exempt)
Starting Wage DOE: $32.06 - $40.07

This position may be eligible for a $3000 sign-on bonus, relocation assistance and tuition loan repayment


The Clinical Documentation Specialist - Inpatient will conduct concurrent review of clinical documentation in the inpatient medical record with the goal to obtain the most accurate and complete physician documentation that appropriately supports the severity of a patient's illness, mortality risk, and proper reimbursement. Responsible to query physicians and other caregivers via written and/or verbal communications for clarification of clinical documentation. He/she works collaboratively with the coding and compliance departments to ensure appropriate final DRG assignments and CC/MCC capture. In collaboration with the RN CCs team will Provides ongoing education related to documentation requirements and opportunities to all providers requirements and opportunities to all providers. Will conduct concurrent and retrospective medical record review for defined patient populations to identify opportunities to improve accuracy of practitioner documentation.

Essential Job Functions


• Supports and models behaviors consistent with Billings Clinic's mission, vision, values, code of
• Meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental, and outside agency
• Performs admission reviews within 24 to 48 hours for patient populations to facilitate
• Conducts ongoing reviews of physician/provider and other clinical documentation, lab results,
• Queries physicians and non-physician providers verbally and in writing daily according to
• Validates that follow-through of accurate documentation has occurred and reports appropriately.
• In collaboration with physicians and coding specialists, identifies and records principal diagnosis,
• Provides education to physicians in a one to one setting regarding documentation specificity and the
• Utilizes medical staff established criteria for complications to assist in appropriate documentation
• Collaborates with clinical coordinator and RN CCS with the coding staff and provides clinical
• Acts as a liaison between coding staff and physicians to resolve questions about documentation and/or coding.??
• Reviews previous Billings Clinic encounters and supporting information in the concurrent electronic
• Ensures appropriate documentation exists for any conditions that were present on admission (POA).
• Participates in process improvement activities with department leadership, department team members, and inter-departmental team members.
• Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental, and outside agency environmental, employee, or p patient safety standards relevant to job performance.
• Performs other duties as assigned or needed to meet the needs of the department/organization

Minimum Qualifications
Education
• Graduate of an approved school of nursing, Bachelor's degree preferred

Experience
• Three (3) years of medical/surgical nursing experience with at least one year of Billings Clinic experience preferred but not required.

Certifications and Licenses
• Certified Coding Specialist CCS, Within 2 years of hire
• Certified Clinical Documentation Specialist (CCDS) Within 2 years of hire
• Certified Documentation Improvement Practitioner (CDIP), Within 2 years of hire
• Certified Professional Coder (CPC), Within 2 years of hire
• Current Montana license as an RN At hire

Or an equivalent combination of education and experience relating to the above tasks, knowledge, skills and abilities will be considered. Employees that require a licensed or certification must be properly licensed/certified and the licensure/certification must be in good standing.

Billings Clinic is Montana's largest health system serving Montana, Wyoming and the western Dakotas. A not-for-profit organization led by a physician CEO, the health system is governed by a board of community members, nurses and physicians. Billings Clinic includes an integrated multi-specialty group practice, tertiary care hospital and trauma center, based in Billings, Montana. Learn more at www.billingsclinic.com/aboutus

Billings Clinic is committed to being an inclusive and welcoming employer, that strives to be kind, safe, and courageous in all we do. As an equal opportunity employer, our policies and processes are designed to achieve fair and equitable treatment of all employees and job applicants. All employees and job applicants will be provided the same treatment in all aspects of the employment relationship, regardless of race, color, religion, sex, gender identity, sexual orientation, pregnancy, marital status, national origin, age, genetic information, military status, and/or disability. To ensure we provide an accessible candidate experience for prospective employees, please let us know if you need any accommodations during the recruitment process.