Clinical Documentation Specialist

Trinity Health; United States; Remote; USD 90,000 - 110,000; Full time

Job summary

Saint Alphonsus Health System seeks a Clinical Documentation Specialist to review medical records and optimize physician documentation for accurate severity of illness and mortality risk.

This remote, full-time role collaborates with physicians, HIM and nursing staff; you will input data into 3M 360 Encompass and Cerner PowerChart and provide education to staff to support compliant documentation improvements.

Qualifications

• Registered Nurse, BSN preferred; or Certified Physician Assistant (PA-C).
• 3 to 5 years of hospital clinical documentation experience required; critical care or medical-surgical background preferred.
• Ability to pass written clinical competency exam.

Responsibilities

• Knows, understands, incorporates, and demonstrates the Organization's 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 patient's 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.

Skills

Clinical documentation

Education

Registered Nurse (RN) with BSN preferred

Certified Physician Assistant (PA-C)

Tools

3M 360 Encompass

Cerner PowerChart

Job description

Employment Type:

Full time

Shift:

Day Shift

Description:

CLINICAL DOCUMENTATION SPECIALIST

REMOTE

SUMMARY AND PURPOSE:

The Clinical Documentation Specialist is responsible for reviewing medical records to facilitate the accurate representation of the patient's severity of illness and risk of mortality by improving the quality of the physician's 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 Organization's 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 patient's 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 region's 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.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.