Clinical Documentation Specialist RN (1.0 FTE, Days)
About The Position
Working under department management the Clinical Documentation Specialist RN ensures the documentation in the patient health record accurately reflects the severity of illness, expected risk of mortality and the level of services provided to the patient. Utilizing defined review and query processes the CDI RN completes a comprehensive review of inpatient medical records and facilitates clinical documentation correction through collaborative interaction with providers, other patient care givers and with the Medical Center Coding Staff to ensure the encounter record is complete and accurate for reimbursement and outcome reporting.
Requirements
- Current State of Washington RN license
- Bachelors of Science degree in Nursing
- Five (5) years of experience as an RN with a minimum of three year’s acute care or case management experience
- Clinical knowledge with recent acute inpatient clinical experience
- Current American Heart Association Healthcare Provider BLS certification by date of hire
- Training in clinical documentation at time of hire or must obtain within three months of hire.
- Knowledge of the healthcare financial environment, reimbursement and levels of care.
- Training in clinical documentation at time of hire or must obtain within three months
- Oral and written language skills; visual and aural skills in order to communicate
- Accountability for professional nursing practice, commitment to patient care and commitment to uphold the Patient Bill of Rights.
Nice To Haves
- Master’s degree in Nursing or other experience and /or educational preparation that would provide the foundation for Nursing Case Management CCDS certification
- CCDS certification
- Recent coding or CDI software
Responsibilities
- Reviews inpatient admissions to identify and improve clinical documentation in the medical record to reflect appropriate severity of illness, risk of mortality and quality of care provided. Uses a worksheet format to document reviews in order to facilitate reporting and process improvement activities.
- Communicates with physicians and coders to ensure accurate and complete documentation in the medical record that reflects the clinical condition of the patient in language that can be coded appropriately.
- Utilizes clinical knowledge and understanding of coding guidelines to analyze clinical information and assign a working DRG
- Formulates compliant and credible clinical documentation queries to improve documentation
- Conducts timely post discharge reviews for clinical validation, DRG mismatches or other documentation clarification need.
- Performs other duties as assigned.
Benefits
- Medical, vision and dental insurance
- On-demand virtual health care
- Health Savings Account
- Flexible Spending Account
- Life and disability insurance
- Retirement plans 457(b) and 401(a) with employer contribution)
- Tuition assistance for undergraduate and graduate degrees
- Federal Public Service Loan Forgiveness program
- Paid Time Off/Vacation
- Extended Illness Bank/Sick Leave
- Paid holidays
- Voluntary hospital indemnity insurance
- Voluntary identity theft protection
- Voluntary legal insurance
- Pay in lieu of benefits premium program
- Free parking
- Commuter benefits
- Cafeteria & Gift Shop Discount
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
