Clinical Documentation Spec

Loma Linda University Health • Loma Linda, CA

2d

About The Position

The Clinical Documentation Specialist conducts concurrent clinical documentation reviews, emphasizing completeness and accuracy of provider documentation regarding the intensity of service required and severity of illness at hospitalization and throughout the patient stay. The specialist initiates verbal and written communication with providers to clarify documentation and support greater specificity or completeness in the medical record. The role also provides formal education on documentation integrity and completeness at medical staff department meetings and committees, and keeps physician leaders in the assigned areas informed about relevant data, documentation trends, and opportunities for learning and improvement. Other duties may be assigned as needed.

Requirements

• Bachelor's degree in Nursing from an accredited school or a bachelor's degree in Health Information Management (HIM). A bachelor's degree in Nursing in progress is acceptable if quarterly updates are provided.
• At least three years of acute hospital nursing or acute hospital coding experience.
• For nurses filling the role, at least one year of recent acute care nursing experience, within the past year.
• For CDS members practicing in pediatric areas, at least three years of pediatric acute hospital nursing experience.
• Able to read, write legibly, and speak English with professional quality.
• Able to use the computer and software programs necessary for the position and troubleshoot and calibrate patient care equipment.
• Able to communicate positively, effectively, and professionally; follow or enforce policies consistently; remain calm and courteous under pressure; lead, supervise, teach, collaborate, and accept direction.
• Able to communicate effectively in English in person, in writing, and by telephone; think critically; work independently with minimal supervision; perform basic math; manage multiple assignments; solve problems; organize and prioritize workload; recall information accurately; and attend closely to detail.
• Able to distinguish colors and smells as necessary for patient care; hear general conversation in person and by telephone; identify workplace or patient-care sounds; see adequately to read computer screens, medical records, and written documents; and discern temperature variances through touch.
• A California Registered Nurse (RN) license is required for nurses filling the role.

Nice To Haves

• Critical Care or Emergency Department experience.
• For CDS members practicing in pediatric areas, PICU or NICU experience.
• Recent experience as an acute hospital utilization reviewer or Case Manager with knowledge of third-party reimbursement requirements.

Responsibilities

• Conduct concurrent clinical documentation reviews focused on completeness and accuracy of provider documentation.
• Review documentation related to intensity of service required and severity of illness upon hospitalization and throughout the patient stay.
• Communicate verbally and in writing with providers to facilitate clarification and improve the specificity or completeness of the medical record.
• Provide formal education on documentation integrity and completeness at medical staff department meetings and committees.
• Keep physician leaders in assigned areas informed about pertinent data, documentation trends, and opportunities for learning and improvement.
• Perform other duties as needed.

What This Job Offers

• Job Type: Full-time