RN Clinical Documentation Specialist

Presbyterian is seeking a RN - Clinical Documentation Specialist

This position is expected to assist medical staff providers with documentation in the medical record. Will be responsible to review physician documentation daily; keep track of patient diagnosis and procedures to reflect the level of service provided. Will work independently and must be able to develop schedule and prioritize the workload to ensure all work is completed. Must be flexible to assist with coverage issues and a team player in consultation with other reviewers and HIM coders. Excellent communication skills are essential for daily interaction and collaboration with physicians and staff to ensure that clinical information in the medical record is present and accurate to support that the appropriate clinical severity is captured for the level of service rendered. This position may encounter resistance due to the perception that information is already adequately documented in the medical record. It requires experience and confidence to address all types of clinical documentation issues and regulatory requirements. The individual must be assertive and tactful to obtain medical staff cooperation

• This is a Full Time position - Exempt: Yes
• Job is based at Presbyterian Hospital
• Work hours: Weekday Schedule Monday-Friday

Ideal Candidate:

• Associates degree in Nursing and 5 years ED RN experience or Bachelors degree with 2 yrs CDI experience

• Associates degree in Nursing and 5 years clinical experience in an acute care facility or Bachelors degree with 2 yrs CDI experience required.
• Achieve CCDS (Certified Clinical Documentation Specialist) within 3 years employment as Clinical Documentation Specialist (CDS).
• Working knowledge of medical terminology ICD-10 CPT HCPCS DRG disease processes and related procedures required.
• Up to date clinical skills and current working knowledge of pathology and pharmacology impacts on care required.
• Experience with database spreadsheet and word process required.
• Detail and results oriented with the ability to maintain accurate detailed and organized records essential.

• Responsible for clinical documentation analysis of the medical record documentation completeness coding accuracy and compliance in either electronic or hard copy form as designated.
• Performs concurrent reviews of the medical record for inpatient admissions to include assignments of DRG identifying complication and co-morbid conditions and specific co-existing conditions and documents findings.
• Works collaboratively with the Medical Staff Nursing Staff and other patient care givers to improve the quality of chart documentation to accurately reflect services provided and present an accurate hospital and physicians profile.
• Assist physicians with documentation requirements to support medical necessity for hospital and physician billing.
• Interprets clinical information in the medical record ordered interventions lab and test results etc. and queries if necessary for supporting documentation in progress notes consultations history and physicals etc. as appropriate.
• Initiates communication to physicians providers verbally or utilizing the appropriate prompter/query tools in order to obtain more specific principal diagnosis or co morbidities and complications. Solicit clarification of existing documentation in the medical record that support patient severity of illness.
• Acts as expert clinical resource for the HIM Coding team working collaboratively to identify areas for clarification of documentation in the medical record that meets regulatory requirements to accurately reflect patient severity of illness and services provided.
• Coordinates with the HIM Coding team related to coding guideline requirements for clinical documentation.
• Collaborates with the HIM Coding team to provide information and education as necessary to physician and other providers not responding to prompters/ queries on documentation requirements.
• Maintains and disseminates up-to-date technical knowledge of legal and regulatory information from all appropriate jurisdictions concerning the given business area. This includes but is not limited to all ICD-10 CPT HCPCS and APC updates and changes. This includes but is not limited to CMS JCAHO Nursing Standards of Practice etc.
• Maintains up-to-date working knowledge of all PHS coding and documentation IT applications.
• Maintains current knowledge of Nursing Practice through seminars workshops publications etc.
• Conducts training classes in areas of coding documentation and compliance for physicians and other providers. This includes preparation of training materials educational audits and answering situational questions.
• Serves as a liaison to other departments providing clinical expertise and consultation.
• Utilizes monitoring tools to track defined measures for progress of documentation accuracy

About Presbyterian Healthcare Services
Presbyterian offers a comprehensive benefits package to eligible employees including medical dental vision disability coverage life insurance and optional voluntary benefits.

The Employee Wellness Rewards Program encourages staff to engage in health-enhancing activities - like challenges webinars and screenings - with opportunities to earn gift to earn gift cards and other incentives.

As a mission-driven organization Presbyterian is deeply committed to improving community health across New Mexico through initiatives like growers markets and local partnerships. Founded in 1908 Presbyterian is a locally owned not-for-profit healthcare system with nine hospitals a statewide health plan and a growing multi-specialty medical group. With nearly 14000 employees it is the largest private employer in the state serving over 580000 health plan members through Medicare Advantage Medicaid and Commercial plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.