Clinical Documentation Specialist - Utilization Management (Full-Time, Days)
About The Position
The Clinical Documentation Specialist (CDS) reviews medical records to facilitate accurate representation of patients’ severity of illness. The role involves extensive record review and interaction with physicians, clinical staff, and Health Information Management professionals. Using advanced clinical knowledge, the CDS reviews records accurately and promptly, identifies opportunities to improve documentation, formulates clinically credible documentation clarifications, follows up on cases in a timely manner—especially those requiring clarification—and communicates effectively and appropriately with physicians. The CDS also participates in Task Force Meetings and collaborates on developing education for medical staff. This is a full-time, day-shift position in Enloe Health’s Utilization Management department. The schedule is an eight-hour shift, with Saturday and Sunday off and 80 hours per pay period.
Requirements
- Five years of inpatient acute care nursing experience.
- Current licensure with the California Board of Registered Nursing.
- Current CPR certification.
- CCDS certification, or must obtain it when eligible to test.
- Excellent verbal and written communication skills and advanced critical-thinking skills.
- Ability to maintain strong, positive working relationships with medical staff.
- Understanding of and support for CDI documentation strategies and concepts.
- Advanced clinical expertise, including knowledge of nursing anatomy and pathophysiology, disease processes, and pharmacology; advanced critical thinking, deductive reasoning, and problem-solving skills.
- Organizational, analytical, and interpersonal skills.
- Strict HIPAA compliance.
- Ability to interact with a wide variety of individuals and handle multiple priorities.
- Computer proficiency, including database programs, presentation programs, word processing, and internet search.
- Ability to work independently, be self-motivated, and adapt to changes in the work environment.
- Ability to interact professionally with colleagues and foster a team environment.
- Ability to perform the essential functions of the position.
Nice To Haves
- CDI experience.
- Critical care experience.
- Bachelor’s or Master’s degree in nursing.
- Experience in hospital operations, management, and physician relations.
Responsibilities
- Review medical records to facilitate accurate representation of severity of illness.
- Conduct extensive record reviews and interact with physicians, clinical staff, and HIM professionals.
- Identify opportunities for documentation improvement and formulate clinically credible documentation clarifications.
- Follow up on cases in a timely manner, especially cases requiring clinical documentation clarification.
- Communicate effectively and appropriately with physicians.
- Participate in Task Force Meetings.
- Collaborate on developing education for medical staff.
Benefits
- $0 premium medical plan, including vision insurance.
- Prescription and dental group insurance.
- Retirement plan with employer match.
- Paid time off plan that begins accruing immediately and can be used as it is earned.
- Extended Sick Leave.
- Flexible Spending Accounts for unreimbursed medical expenses and dependent care.
- Employee Assistance Program.
- Educational Assistance.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
