Clinical Documentation Specialist - Utilization Management (Full-Time, Days)

Enloe Medical Center, Inc.; Chico (CA); On-site; USD 71,000 - 96,000; Full time

Benefits offered by this job

Zero-premium medical plan (vision)

Dental and prescription insurance

Employer match retirement

PTO accrual from day one

Extended sick leave

Flexible Spending Accounts

Employee Assistance Program

Educational Assistance

Job summary

Enloe Health is seeking a Clinical Documentation Specialist (CDS) to review medical records and ensure accurate severity of illness. You will interact with physicians, clinical staff, and HIM professionals to identify documentation improvements and provide clarifications.

Minimum five years of inpatient nursing experience is required; California RN licensure and CPR certification are needed. A Bachelor’s or Master’s in Nursing is preferred, with CCDS certification encouraged.

Qualifications

• Minimum: Five years inpatient acute care nursing experience.
• CDS experience and hospital operations exposure are desirable.
• Bachelor’s or Master’s degree in nursing; CA RN licensure.

Responsibilities

• Review medical records to ensure accurate severity of illness.
• Identify documentation improvements and clarify clinically questionable cases.
• Collaborate with physicians, HIM staff, and education teams.

Skills

Verbal and written communication

Critical thinking

HIPAA compliance

Nursing knowledge

Interpersonal skills

Education

California RN license

Bachelor's or Master's in Nursing

CDDS/CDS experience

Tools

Database software

Presentation software

Word processing

Job description

ENL Utilization Management Compensation range: $51.76 - $69.88 Your rate of pay will be based on applicable experience Shift: Days Shift length: 8 Hours Days off: Saturday & Sunday Hours per pay period: 80 Hours Enloe Health is a Level II Trauma Center located in beautiful Northern California. We offer a full array of medical services, and our mission is to elevate the health of the communities we serve. As a Planetree organization, we place high value on hiring the right team to care for our patients and their families—care that is steeped in compassion, human connection, and mutual support. If you feel called to make a meaningful impact through empathetic, person-centered care, and thrive in a culture that values collaboration and purpose, we welcome you to join our team.

POSITION SUMMARY:

The Clinical Documentation Specialist (CDS) is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness. This involves the extensive record review, interaction with physicians, clinical staff, and HIM professionals. Utilizing advanced clinical knowledge, the CDS role requires the ability to review the medical record accurately and timely, recognize opportunities for documentation improvements, formulate clinically credible documentation clarifications, follow-up timely on all cases, especially those requiring clinical documentation clarifications, and communicate effectively and appropriately with the physicians. The CDS participates in the Task Force Meetings and collaborates on developing education for medical staff.

EDUCATION / TRAINING / EXPERIENCE:

Minimum: Five years inpatient acute care nursing experience Desired: CDI Experience Critical Care Experience Bachelor’s or Master’s degree, in nursing Experience in hospital operations, management and physician relations

LICENSES / CERTIFICATIONS:

Minimum: Current licensure with the California Board of Registered Nursing Current CPR certification CCDS Certification (or must obtain when eligible to test) (dept tracks)

SKILLS / KNOWLEDGE / ABILITIES:

Must have excellent verbal and written communication skills and advanced critical thinking skills and be able to maintain strong, positive working relationships with medical staff. Understands and supports the CDI documentation strategies and concepts. Demonstrates advanced clinical expertise including understanding of nursing anatomy/pathophysiology, disease processes, pharmacology, advanced critical thinking, deductive reasoning and problem solving skills. Demonstrates organizational, analytical and interpersonal skills. Requires strict HIPPA compliance. Demonstrates ability to interact with a wide variety of individuals and handle multiple priorities. Proficiency in computer use, including database programs, presentation programs, word processing and internet search. Ability to work independently, be self-motivated, and adaptable to changes in work environment. Must be able to interact professionally with various colleagues and foster a team environment. Must be able to perform the essential functions of the position.

Benefits Information

Enloe offers a comprehensive and competitive benefits package to all eligible employees, including, but not limited to:

• $0 premium medical plan to include vision insurance
• Prescription and dental group insurance
• Retirement with employer match
• Generous paid time off (PTO) plan that starts accruing immediately and can be used as it's earned
• Extended Sick Leave
• Flexible Spending Accounts for unreimbursed medical expenses and dependent care
• Employee Assistance Program
• Educational Assistance

Please visit the employee benefits page at http://www.enloe.org/benefits to get more in-depth benefits and coverage information.

A proud nonprofit health system, Enloe Health has served the people of the North State for more than 110 years. At Enloe, every employee, staff member and volunteer is a caregiver. No matter our role, each of us is here for our patients. Enloe values our workforce and is proud to be recognized as an excellent employer.