Clinical Documentation Spec

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

Job summary

The Clinical Documentation Specialist at Loma Linda University Health conducts concurrent reviews to ensure accurate and complete provider documentation regarding patient condition and care during hospitalization. The role involves proactive communication with clinicians to clarify documentation needs and to improve record quality.

Responsibilities include providing formal education on documentation integrity at staff meetings and committees, and informing physician leaders of trends and

Qualifications

• Bachelor's degree required in nursing or HIM; progress in nursing acceptable with updates.
• RN license with California registration is required for the role.
• Clinical experience in acute hospital settings is essential.

Responsibilities

• Perform concurrent clinical documentation reviews focusing on accuracy and completeness.
• Communicate with providers to obtain clarifications for documentation gaps.
• Educate medical staff on documentation integrity in meetings and committees.

Skills

Clinical documentation

Communication

Critical thinking

Education delivery

Team collaboration

Education

Bachelor's degree in Nursing

Bachelor's degree in Health Information Management

Nursing in progress acceptable

Tools

EMR systems

Job description

MC: Patient Safety and Reliabi- (Full Time, Days) -

Job Summary:

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.

Licensures and Certifications:

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