Clinical Documentation Spec

Loma Linda University Health; Loma Linda (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

Loma Linda University Health is seeking a Clinical Documentation Specialist (Full Time, Days) to perform concurrent reviews emphasizing completeness and accuracy of provider documentation related to intensity of service and severity of illness during hospitalization and stay.

You will clarify documentation with providers, deliver education on documentation integrity at medical staff meetings, and report trends to physician leaders.

Qualifications

• Bachelor's Degree in Nursing or HIM required; nursing in progress acceptable with quarterly updates provided.
• Minimum three years acute hospital nursing or acute hospital coding experience required.
• For nurses filling role one year of recent acute care nursing experience required.
• Pediatric CDS: minimum three years pediatric acute hospital nursing experience; PICU/NICU preferred.

Responsibilities

• Perform concurrent clinical documentation review focusing on completeness and accuracy of provider documentation.
• Initiate communication with providers to facilitate clarification of need for greater specialty or completeness of the medical record.
• Provide formal education related to documentation integrity at medical staff department meetings and committees.
• Keep physician leaders informed of pertinent data, documentation trends, and opportunities for learning and improvement.

Skills

Clinical documentation

Nursing experience

Healthcare coding

Interdisciplinary communication

Education and training

Education

Bachelor's Degree in Nursing

Bachelor's Degree in Health Information Management

Nursing in progress

Job description

MC: Clinical Documentation Imp- (Full Time, Days)

The Clinical Documentation Specialist is responsible for concurrent clinical documentation review with an emphasis on completeness and accuracy of provider documentation related to intensity of service required and severity of illness upon hospitalization and throughout patient stay. Initiates communication, verbal and written, with providers to facilitate clarification of need for greater specialty or completeness of the medical record. Provides formal education related to documentation integrity and completeness at medical staff department meetings and committees. Keeps physician leaders in areas of responsibility informed of pertinent data, documentation trends, and opportunities for learning and improvement related to documentation integrity. Performs other duties as needed.

Education and Experience

Bachelor's Degree in Nursing from an accredited school or Bachelor's Degree in Health Information Management (HIM) required. Bachelor's Degree in Nursing in progress acceptable with quarterly updates provided. Minimum three years of acute hospital nursing or acute hospital coding experience required. For nurses filling role one year of recent (within one year) acute care nursing experience required. Critical Care or ED experience preferred. For CDS members practicing in pediatric areas, minimum three years of pediatric acute hospital nursing experience required, PICU or NICU preferred.

Knowledge and Skills

Recent experience as acute hospital utilization reviewer or Case Manager with knowledge of third party reimbursement requirements preferred. Able to read; write legibly; speak in English with professional quality; use computer and software programs necessary to the position; troubleshoot and calibrate patient care equipment. Able to relate and communicate positively, effectively, and professionally with others; be assertive and consistent in following or enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, and collaborate; accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; work independently with minimal supervision; performs basic math functions; manage multiple assignments effectively; work well under pressure; problem solve; organize and prioritize workload; recall information with accuracy; pay close attention to detail. Able to distinguish colors and smells as necessary for patient care; hear sufficiently for general conversation in person and on the telephone; identify and distinguish various sounds associated with the work place or patient care; see adequately to read computer screens, medical records, and written documents necessary to position; discern temperature variances through touch.

Licenses and Certifications

California Registered Nurse (RN) License required for nurse filling role.

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