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

Enloe Health; United States; Remote; USD 71,000 - 96,000; Full time

Benefits offered by this job

0 premium medical plan with vision

Prescription & dental insurance

Employer match retirement

Paid time off (PTO)

Extended Sick Leave

Flexible Spending Accounts

Employee Assistance Program

Educational Assistance

Job summary

Enloe Health in California seeks a Clinical Documentation Specialist to review inpatient medical records and ensure accurate severity-of-illness representation. You will collaborate with physicians, nurses and HIM staff to clarify documentation and improve coding accuracy.

The role requires five years of inpatient nursing experience, CDI/CCDS exposure preferred, and active RN licensure in California. On-site days, with weekend days off, and a comprehensive benefits package are provided.

Qualifications

• Five years inpatient acute care nursing experience.
• Excellent communication skills (verbal and written).
• Strong clinical knowledge including nursing anatomy/pathophysiology and pharmacology.

Responsibilities

• Review medical records to ensure accurate severity of illness representation.
• Interact with physicians, clinical staff and HIM professionals for record review and clarifications.
• Identify opportunities for documentation improvements and formulate credible documentation clarifications.
• Follow-up on cases, especially those needing clarifications, with timely communication to physicians.
• Participate in Task Force Meetings and help develop education for medical staff.

Education

Five years inpatient acute care nursing experience

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 or email [e-mail] to receive a full summary of benefits.