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

Enloe Health • Chico, CA

9d

About The Position

The Clinical Documentation Specialist (CDS) reviews medical records to facilitate accurate representation of the severity of illness. The role involves extensive record review and interaction with physicians, clinical staff, and Health Information Management (HIM) 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 participates in Task Force Meetings and collaborates on developing education for medical staff.

Requirements

• At least five years of inpatient acute care nursing experience.
• Current licensure with the California Board of Registered Nursing.
• Current CPR certification.
• CCDS certification, or 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 nursing anatomy and pathophysiology, disease processes, pharmacology, deductive reasoning, and problem-solving.
• Organizational, analytical, and interpersonal skills.
• Strict HIPAA compliance.
• Ability to interact with a wide variety of individuals and handle multiple priorities.
• Proficiency with computers, including database and 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.
• Interact with physicians, clinical staff, and HIM professionals as part of record review.
• Identify opportunities for documentation improvement and formulate clinically credible documentation clarifications.
• Follow up on cases in a timely manner, especially cases requiring clinical documentation clarifications.
• 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.
• Generous paid time off (PTO), accruing immediately and usable as earned.
• Extended Sick Leave.
• Flexible Spending Accounts for unreimbursed medical expenses and dependent care.
• Employee Assistance Program.
• Educational Assistance.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed