Clinical Documentation Specialist, Clinician

Sutter Health • Plantation, FL

89d • $37 - $103

About The Position

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.

Requirements

• Graduate of an accredited school of nursing OR Foreign trained physician.
• RN-Registered Nurse of California OR Foreign trained physician.
• 5 years recent relevant experience.
• Clinical knowledge of diagnoses, severity of illness, risk of mortality, co-morbidities and complications.
• Knowledge of age-specific needs and 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.
• Ability to define issues, collect data, establish facts and draw valid conclusions.
• Demonstrates a proactive approach in identifying and addressing issues.
• Collaboration skills to facilitate open sharing of information.
• Displays a customer service focus in all decisions and actions.
• Ability to communicate through verbal and written means.
• Ability to create and translate data into reports and presentations.
• Organization skills to effectively manage and/or re-prioritize activities.
• Ability to interact and maintain effective working relationships.
• Demonstrates respect for cultural and linguistic differences.
• Demonstrates initiative in providing feedback/input to improve workflow.
• Ability to work effectively in a dynamic and fast-paced environment.
• Ability to maintain and work discreetly with confidential information.
• Ability to use essential applications and/or databases associated with the role.

Responsibilities

• Conduct concurrent and retrospective reviews of patient medical records.
• Evaluate the accuracy and completeness of clinical documentation.
• Ensure notes reflect the severity of patient's illness and quality of care.
• Interact with physicians, patient care team, and ancillary departments.
• Gather and clarify medical record documentation.
• Identify opportunities for improvement in documentation requirements.
• Optimize reimbursement for the level of service rendered.
• Enhance measurement and reporting of outcomes.

Benefits

• Comprehensive benefits package.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Nursing and Residential Care Facilities
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees