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Clinical Documentation Specialist/ Registered Nurse

DEFINITION:
A Clinical Documentation Specialist is an individual who concurrently reviews medical records to facilitate appropriate physician documentation in order to accurately reflect patient severity of illness and risk of mortality.
POSITION
Summary:
The Clinical Documentation Specialist (CDS) facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of service rendered to all inpatients.
The CDS will:
o Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans;o Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital's designated clinical documentation policies and procedures;o Communicate with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness;o Communicate with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record;o Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team;o Gather and analyze information pertinent to documentation findings and outcomes.
KNOWLEDGE:
o RN diploma or Associate Degree required, B.
S.
degree preferred.
o Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting.
o Working knowledge of quality improvement theory and practice .
o Knowledge of principals of information management in order to effectively analyze and make decisions.
o Knowledge of federal, state and private payer regulations .
SKILLS:
Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and internet searching.
Excellent technical/clinical reading, writing, and verbal skills.
Proficiency in organization and planning.
Working knowledge of quality improvement theory and practice.
Ability to respond appropriately to customer/coworker by projecting a professional, friendly, helpful demeanor.
Proficient in problem solving, assessing, and using alternative approaches.
Ability to work independently and take initiative.
Ability to set priorities and use good judgment.
Ability to incorporate into practice, advanced clinical skills, theoretical concepts, and knowledge of health care finances.
Ability and willingness to seek out and accept change; to deal effectively with change and ambiguity.
Demonstrated adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice.
Ability to travel between facilities as necessary.
Score of 80% or above on Pre-Hire Appraisal within the first 60 days of employment.
Experience:
Clinical expert with at least three (3) years recent inpatient experience.
LICENSE:
Current Valid California Registered Nursing License.
Current CPR.


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