Clinical Documentation Specialist

• OUR VISION: Creating America’s healthiest community, together

OUR MISSION: In the spirit of love and compassion, better health, better care, better value

OUR VALUES: Accountability, Caring and Teamwork

Department

Summary

TheClinical Documentation Department performs concurrent and selected retrospective medical record reviews in order to facilitate appropriate provider documentation that captures the most complete and accurate clinical conditions impacting patient visits.

Position

Overview

TheClinical Documentation Integrity Specialist II at St. Charles Health System provides clinical based review and analysis of the documentation in the patient’s medical record to support accurate capture of patient’s complexity and severity of illness. Utilizes queries of the medical staff and other caregivers to clarify and support completeness of documentation.

This position does not directly manage any other Caregivers.

Essential functions and

Duties

Collaborates with physician, mid-level providers, ancillary staff, and medical records coders to identify principle and secondary diagnoses, and principle procedures. Also reviews for quality indicators.

Maintains current knowledge of Medicare’s rules, regulations, and guidelines.

Conducts initial and ongoing concurrent and some retrospective reviews for system wide admissions for all payors, initiates tracking process, and documents findings on EHR tracking system.

Identifies when there is a need to clarify documentation in patient records and initiates queries or communication with providers to capture accurate documentation of the patient’s severity of illness and risk of mortality in compliance with all guidelines and requirements.

Provides information and education as necessary to providers on an ongoing basis. Collaborates with Physician Advisor to present specialty specific and/or individual education. Independently attends provider service line meetings or team meetings to serve as a resource and/or educate on documentation opportunities.

Volunteers for special projects in the department such as developing education materials/presentations, tip sheets, present teaching opportunities to co-workers, etc.

Complies with all applicable laws, regulations, policies and procedures, supporting the health system’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violations of applicable rules, and cooperating fully with all company investigations and proceedings.

Supports the vision, mission, and values of the organization in all respects.

Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.

Provides and maintains a safe environment for caregivers, patients, and guests.

Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient, and accurate.

May perform additional duties of similar complexity within the organization, as required or assigned.

Education

Required: As required by licensure for RN. Preferred: BSN

Licensure/certification/registration

Required: Current Oregon RN License. CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner). Continue to obtain CE credits required to maintain re-certification in CCDS or CDIP. Preferred: N/A

Experience

Required: Minimum of two (2) years recent CDIS experience. Preferred: Proficient use of EPIC and 3M 360 Encompass software programs.

Personal protective equipment

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

Additional position information

General Ability to virtually attend business functions/trainings/meetings during general business hours in the Pacific Time Zone. Ability to work in a productivity-based department. Ability to maintain focus while reviewing medical records for the majority of the work day. Ability to adapt to frequent industry and/or process changes.

Communication/Interpersonal Must have excellent communication skills and ability to interact with a diverse population and professionally represent SCHS. Ability to effectively interact and communicate with all levels within SCHS and external customers/clients/potential employees. Strong team working and collaborative skills. Ability to effectively reach consensus with a diverse population with differing needs.

Organizational Ability to multi-task and work independently. Attention to detail. Excellent organizational skills, written and oral communication and customer service skills, particularly in dealing with stressful personal interactions. Strong analytical, problem solving and decision-making skills.

Physical

Requirements

Continually (75% or more): Sitting, keyboard operation, use of clear and audible speaking voice and the ability to hear normal speech level. Frequently (50%): Standing, lifting 1-10 pounds, grasping/squeezing. Occasionally (25%): Bending, reaching overhead, carrying/pushing, or pulling 1-10 pounds.

Rarely (10%): Walking, stooping/kneeling/crouching, climbing stairs. Never (0%): Climbing ladder/stepstool, lifting/carrying/pushing, or pulling 11-50 pounds, operation of a motor vehicle, ability to hear whispered speech level. Exposure to Elemental Factors Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface.

Blood-Borne Pathogen (BBP) Exposure Category No Risk for Exposure to BBP

Schedule Weekly Hours

40

Caregiver Type

Regular

Shift

First Shift (United States of America)

Is Exempt Position? Yes

Job Family

Non contract RN specialist

Scheduled Days of the Week

Monday-Friday

Shift Start End Time

08:00-16:00