Clinical Documentation Specialist

CLINICAL DOCUMENTATION SPECIALIST

REMOTE

SUMMARY AND PURPOSE:

The Clinical Documentation Specialist is responsible for reviewing medical records to facilitate the accurate representation of the patients severity of illness and risk of mortality by improving the quality of the physicians clinical documentation. This involves extensive record review interaction with physicians Health Information Management (HIM) professionals and nursing staff. Active participation in team meetings and education of medical nursing and ancillary staff is a key role.

REQUIREMENTS:

• Registered Nurse BSN preferred; or Certified Physician Assistant (PA-C).

• 3 to 5 years of demonstrate-able hospital clinical documentation experience required. Critical care or strong medical surgical background preferred.

• Ability to pass written clinical competency exam.

WHAT YOU WILL DO:

• Knows understands incorporates and demonstrates the Organizations Mission Vision and Values in behaviors practices and decisions.

• Ability to quickly learn and develop the skills necessary to perform the CDS role including ability to accurately input relevant data into 3M 360 Encompass and Cerner PowerChart (special purpose software).

• Revenue Management

• Ensure physician documentation contains adequate indicators to support the coding of diagnoses representative of each patient.

• Able to audit for accuracy in a timely manner and follow up on all cases quickly especially those with clarifications.

• Formulates credible and compliant clarifications to improve clinical documentation of principle diagnosis co-morbidities evidence of indicators representing conditions present on admission (POA) and quality core measures.

• Facilitates modifications to clinical documentation of the medical record through extensive interaction with physicians nurses and ancillary staff.

• Develops and implement plans of education of physicians nursing and ancillary staff on documentation improvement.

• Reviews inpatient medical records for all payer populations on admissions and throughout hospitalization.

• Analyzes clinical information to identify areas within the chart for potential gaps in physician documentation.

• Able to communicate effectively and appropriately with individuals at all levels of the organization.

• Actively participate in cross functional Task Force meetings.

• Works collaboratively with the coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patients clinical status and care. Able to effectively communicate with HIM staff and resolve discrepancies.

• Responsible for completing all annual regulatory compliance education as well as CDS-specific assigned education.

• Understand and support compliant documentation strategies.

• Knowledge of pathophysiology and disease process.

• Knowledge of regulatory environment essential; knowledge of Medicare Part A and Part B is preferred.

• Excellent organizational analytical and writing skills.

• Ability to demonstrate critical thinking problem solving and excellent interpersonal skills.

• Excellent time management skills and the ability to manage multiple priorities effectively.

HEALTH SYSTEM INFORMATION:

Saint Alphonsus Health System is a faith-based ministry and not-for-profit health system serving Idaho Oregon and northern Nevada communities. The health system boasts 4 hospitals 609 licensed beds and 73 clinic locations. Through innovative technologies compassionate staff and healing environments Saint Alphonsus goal is to improve the health and well-being of people by emphasizing care that is patient-centered physician-led innovative and community-based.

• Top 15 Health Systems in the country by IBM Watson Health;

• The regions most advanced Trauma Center (Level II);

• Commission on Cancer Accredited Program through demonstrating an uncompromising commitment to improving patient survival and quality of life

Saint Alphonsus and Trinity Health are committed to promoting diversity in its workforce and to providing an inclusive work environment where everyone is treated with fairness dignity and respect. We are committed to recruit and retain a diverse staff reflective of the communities we serve. Saint Alphonsus and Trinity Health are equal opportunity employers and prohibit discrimination against any individual with regard to race color religion gender marital status national origin age disability sexual orientation or any other characteristic protected by law.