RN - Clinical Documentation Specialist

Providence • Everett, WA

21h • Onsite

About The Position

The Clinical Documentation Specialist (CDS) is responsible for supporting and facilitating the overall quality of medical record documentation by improving the completeness, accuracy, and reliability of clinical documentation. A key success factor of this process is educating providers through the query process and independently supporting them with education and feedback to accurately reflect the patient's true clinical picture within the medical record. In partnering with the coding team, the CDS will be an expert with ICD-10, NS-DRG and APR-DRG assignment. The CDS's primary responsibility will be to obtain appropriate clinical documentation through extensive review of provider, nursing, ancillary, and other patient caregivers' documentation, to ensure that appropriate documentation and reimbursement is received for the level of services rendered to patients. The CDS exercises their judgment and discretion to ensure the clinical information utilized in analyzing and reporting outcomes is complete and accurate. On an ongoing basis, the CDS is responsible for supporting the direction and focus of education for providers and the coding staff within their assigned scope of work. The CDS must exercise independent judgment, critical thinking, ability to work independently while interpreting and following CMS guidelines, organizational policies, and procedures. Providence caregivers are not simply valued – they’re invaluable. Join our team at Providence Regional Medical Center Everett and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.

Requirements

• Associate's Degree - Associate of Science in Nursing.
• Registered Nurse License upon hire.
• 5 years - Experience as an RN in acute care setting within the last 5 years OR 2-3 years Clinical Documentation Integrity experience in acute care setting.

Nice To Haves

• Bachelor's Degree - Bachelor of Science in Nursing or a Bachelor of Science degree in healthcare or other related field.
• 5 years - Hospital experience in ICU, ED or Medical/Surgical
• 1 year - Understanding of MS-DRG and APR-DRG assignment and fundamentals of establishing a DRG.
• 1 year - ICD-10 experience and/or understanding

Responsibilities

• Supporting and facilitating the overall quality of medical record documentation by improving the completeness, accuracy, and reliability of clinical documentation.
• Educating providers through the query process and independently supporting them with education and feedback to accurately reflect the patient's true clinical picture within the medical record.
• Partnering with the coding team to be an expert with ICD-10, NS-DRG and APR-DRG assignment.
• Obtaining appropriate clinical documentation through extensive review of provider, nursing, ancillary, and other patient caregivers' documentation, to ensure that appropriate documentation and reimbursement is received for the level of services rendered to patients.
• Exercising judgment and discretion to ensure the clinical information utilized in analyzing and reporting outcomes is complete and accurate.
• Supporting the direction and focus of education for providers and the coding staff within their assigned scope of work.
• Exercising independent judgment, critical thinking, ability to work independently while interpreting and following CMS guidelines, organizational policies, and procedures.

Benefits

• Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree