Clinical Documentation Specialist, Clinician

Sutter Health; United States; Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization seeks a professional to perform comprehensive reviews of clinical documentation, ensuring accuracy and compliance. Candidates should have a nursing degree or be a foreign-trained physician with significant relevant experience. This full-time role requires strong analytical skills and collaboration with various healthcare teams to enhance patient care documentation and optimize service reimbursement.

Benefits

Comprehensive benefits package

Qualifications

• Graduate from nursing school or foreign trained physician required.
• Active RN license in California or equivalent.
• 5 years of relevant experience required.

Responsibilities

• Conduct concurrent and retrospective reviews of patient medical records.
• Interact with physicians and patient care teams to clarify documentation.
• Identify improvement opportunities in documentation practices.

Skills

Critical thinking

Clinical knowledge of diagnoses

Collaboration skills

Communication skills

Organization skills

Education

Graduate of an accredited school of nursing

Registered Nurse of California

Tools

Essential applications and databases

Job description

We are so glad you are interested in joining Sutter Health!

Organization:

SHSO-Sutter Health System Office-Valley

Position Overview:

Conducts concurrent and retrospective reviews of patient medical records to evaluate the accuracy and completeness of clinical documentation, ensuring notes reflect the severity of patient's illness and quality of care. Interacts thoughtfully and effectively with physicians, patient care team, and ancillary departments to gather and clarify medical record documentation. Identifies opportunities for improvement to ensure understanding of documentation requirements, optimize reimbursement for the level of service rendered, and enhance the measurement and reporting of outcomes.

Job Description:

EDUCATION:

• Graduate of an accredited school of nursing OR Foreign trained physician

CERTIFICATION & LICENSURE:

• RN-Registered Nurse of California OR Foreign trained physician

TYPICAL EXPERIENCE:

• 5 years recent relevant experience.

SKILLS AND KNOWLEDGE:

• Clinical knowledge of diagnoses, severity of illness, risk of mortality, co-morbidities and complications.
• Knowledge of age-specific needs and the elements of disease processes and related procedures.
• Knowledge of current coding classification and reimbursement guidelines and regulations.
• Critical thinking with the ability to analyze and interpret medical record/clinical documentation and formulate appropriate physician queries.
• Ability to define issues, collect data, establish facts and draw valid conclusions.
• Demonstrates a proactive approach in identifying and addressing issues and concerns.
• Collaboration skills to facilitate open sharing of information and cooperation with various stakeholders to problem solve and achieve desired results/outcome.
• Displays a customer service focus in all decisions and actions.
• Ability to communicate through verbal and written means, and to present information to a variety of audiences.
• Ability to create and translate data into reports and presentations for appropriate audience.
• Organization skills to effectively manage and/or re-prioritize activities and projects to meet deadlines while maintaining a high degree of responsiveness.
• Ability to interact and maintain effective working relationships with those contacted in the performance of required duties.
• Demonstrates respect for cultural and linguistic differences and promotes an inclusive work environment.
• Demonstrates initiative in providing feedback/input to improve workflow/processes.
• Ability to work effectively in a dynamic and fast-paced environment with changing business priorities.
• Ability to maintain and work discreetly with confidential information.
• Ability to use essential applications and/or databases associated with the role’s duties and responsibilities.

Job Shift:

Days

Schedule:

Full Time

Shift Hours:

8

Days of the Week:

Monday - Friday

Weekend Requirements:

None

Benefits:

Yes

Unions:

No

Position Status:

Non-Exempt

Weekly Hours:

40

Employee Status:

Regular

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $79.32 to $103.87 / hour. Pay Transparency Name New Jersey, Washington Pay Range is $79.32 to $103.87 / hour. Colorado, Florida, Georgia, Illinois, Michigan, Minnesota, Nevada, North Carolina, Ohio, Oregon, Pennsylvania, Texas, Virginia Pay Range is $41.00 to $53.83 / hour. Arizona, Arkansas, Idaho, Louisiana, Missouri, Montana, South Carolina, Tennessee, Utah Pay Range is $37.37 to $48.94 / hour.

The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.