• Senior Clinical Documentation Specialist

    Location US-FL-Remote
    Job ID
    Clinical Documentation - Clinical Documentation
    Pos. Type
    Full Time
  • Company Overview

    At Nuance, we empower people with the ability to seamlessly interact with their connected devices and the digital world around them.  We are creating a world where technology thinks and acts the way people do by designing the most human, natural, and intuitive ways of interacting with technology.


    Our nimble technology uses analytics and advanced algorithms to transform the inanimate into animate and reduce complicated processes into simple ones.


    Join our Healthcare team...caring for clinicians the way they care for patients. Beyond words. We create technology that lets clinicians capture and document care quickly and easily so they can focus their attention on their patients.

    Job Summary

    General Summary:   The remote CDS facilitates accurate documentation for severity of illness and quality in the medical record.  This involves extensive record review, interaction with physicians, and health information management professionals, and proficiency in multiple software applications.  Active participation in team meetings and on-time completion of training and continuing education requirements is required. 


    Professional Competencies:  Job functions reflect the following objectives


    1. Conducts clinical review of medical record documentation for completeness and accuracy.
    2. Reviews 8-10 cases/day and follows up on 85% of existing cases each day.
    3. Demonstrates proficiency in the use of Nuance CDI software applications.
    4. Identifies concurrent documentation improvement opportunities to improve severity of illness and relative weight.
      1. Identifies correct concurrent initial and possible DRG in Nuance CDI software.
      2. Correctly sequences DRG to reflect the highest level of severity when two or more diagnoses are present on admission and equally meet the definition of principal diagnosis.
      3. Completes all required weekly, monthly, and quarterly CDI competencies and education modules/offerings.
    5. Generate compliant and clinically valid clarifications to providers using Nuance CDI best practices for worksheets and clarifications.
      1. Clarifies for diagnoses using the 360 format.
      2. Generates clarifications to ensure documented conditions in the medical record are clinically valid, present on admission, consistent, and not conflicting.
    6. Utilizes process flow map for concurrent and post discharge CDI processes.
    7. Collaborates and communicates effectively with client and Nuance management and team members.
    8. Utilizes knowledge of CMS and regulatory environment to inform daily practice, including coding clinics and coding guidelines.
    9. Performs peer audits, as required, to provide feedback for team improvement.
    10. Performs tasks related to securing and keeping the products, tools, and processes that you are responsible for security


    Education, Skills and Abilities:   


    1. License & Certifications: Registered Nurse licensure in the state in which you are based, or Physician Assistant Certification.   In this position, one may be required to obtain licensure in additional states. CCDS or CDIP a plus.


    1. Education: Associates Degree in Nursing (ADN) required.  Bachelor’s Degree in Nursing or related field preferred, or Degree in Physician Assistant Studies.


    1. Experience:  One or more years of experience as a CDS are required.  Five years minimum experience in an acute care area such as ED, Critical care is required.  Extensive medical-surgical nursing may experience may also apply.   Preceptorship, leadership/project management experiences a plus.     


    1. Must have the ability to:


    • Lift 25-50 lbs of luggage
    • Walk or stand for extended time periods
    • Travel by air, car, or both 
    • Effectively communicate (verbal and written) with coworkers, management, customers, and others in a courteous and professional manner, as well as timely responsiveness to emails, phone mails, and verbal requests.
    • Communicate problems and issues in a professional manner, and identify solutions.
    • Provide uncompromising customer service to all client groups.
    • Remain organized using a daily work flow, but able to handle interruptions and high priority requests.
    • Use Windows-based software packages particularly Microsoft Office products.
    • Anticipate and resolve potential problems by taking ownership and personal accountability.
    • Analyze moderately complex problems using structured problem solving skills, generating necessary data from appropriate sources.
    • Maintain confidentiality and security of all JA Thomas proprietary information and data.

    Working Conditions:

    1. Must be able to work remotely, at least 75% of the time, with a private space in the home away from distractions, family members, and noise that will allow privacy of confidential information.
    2. Up to 25% annual travel is required to service the needs of our customers. Depending on business needs this travel requirement may result in a variety of scenarios to include but not limited to 1-2 days each week, 1 week every month or 3 months each year.
      1. The total number of days worked away from home will not exceed 90 days annually
      1. Travel to and from home to a client site for work is consecutive days
      2. Travel on Sunday may be required.
      3. Travel days are not included in the count of days worked away from home.


    1. Work additional hours/schedules as needed to complete assignments or meet deadlines.


    1. Maintain a daily schedule that allows team interaction, ability to attend meetings, join calls, and provide client services during normal hours of operation.


    1. Capable of extended periods of sitting.


    1. All other duties as assigned or necessary.



    This document is intended to describe the generalized duties and responsibilities, the specialized job functions, and the essential requirements of this job.  It is not intended to be an exhaustive statement of all supplemental duties, responsibilities, or non-essential requirements or reflect any accommodations made under the American’s with Disability Act. 


    Additional Information

    Nuance offers a compelling and rewarding work environment. We offer market competitive salaries, bonus, equity, benefits, meaningful growth and development opportunities and a casual yet technically challenging work environment. Join our dynamic, entrepreneurial team and become part of our continuing success.  


    Nuance Communication Inc.  is an equal opportunity employer.  We evaluate qualified applicants without regard to race, age, color, religion, sex, national origin, disability, veteran status, gender identity, sexual orientation and other legally protected characteristics. The EEO is the Law poster and its supplement is available here. If you need a reasonable accommodation because of a disability for any part of the employment process, please call 781-565-5086 – Human Resources Department and let us know the nature of your request and your contact information.


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