Clinical Documentation Specialist RN

Work Status Details: PRO RE NATA - AS NEEDED | 16.00 Hours Every Two Weeks
Shift: Weekends ONLY - Days
Pay Rate Type: Hourly
Location: Yuma Medical Center

Listed is the base hiring salary range offered for this position. Actual salaries may vary depending on factors, including but not limited to skills and experience. The salary range listed is just one component of the total rewards/compensation package offered to candidates.
Min = $33.74
Mid = $42.17
Max = $50.61

Summary:

The Clinical Documentation Specialist RN facilitates accurate documentation for severity of illness and quality in the patient medical record and is responsible for improving the overall quality, completeness, and compliance of clinical documentation. The Clinical Documentation Specialist RN ensures clear, concise, complete, appropriate, and compliant documentation is present in the patient record reflecting the intended assessment, treatment plan, and care objectives or outcomes formulated by the clinical staff such that proper reimbursement for level of service rendered is validated and obtained in a timely manner.

Responsibilities:

The Clinical Documentation Specialist RN facilitates accurate documentation for severity of illness and quality in the patient medical record and is responsible for improving the overall quality, completeness, and compliance of clinical documentation. This involves extensive concurrent record review, interaction with physicians, health information management professionals, and nursing staff. 

Reviews inpatient medical records to identify payer source (Medicare, Blue Cross/Blue Shield) upon admission and throughout hospitalization and effectively communicated differences between Medicare Part A and Part B guidelines and how they impact DRG assignments to medical staff.

Utilizes knowledge of Core Measure and Patient Safety Indicators when reviewing and analyzing selected inpatient medical records for all of the following, including but not limited to: chief complaint; presentation; history of present illness; past medical, surgical, and social history; clinical status of patient; diagnostic tests, evaluations, and studies; clinical decision making; and treatment plan, in order to identify potential gaps in clinical documentation; meets established productivity targets for record review as determined by Director.

Interacts and directly communicates with attending physicians and medical staff (physicians, physician assistants, and advanced practice nurses), nursing staff, and other patient care providers both verbally or in written form on a concurrent basis to validate observations and suggest additional and /or more specific clinical documentation.

Works closely with professional coding staff to assure documentation of discharge diagnosis and any co-existing co-morbid conditions (CC's) are a complete reflection of the patient's clinical status and care by demonstrating basic knowledge about standards of coding and applying ongoing evaluation of inpatient medical record clinical documentation.

Recommends and implements, under collaboration and direction of Director and physician leadership, specific tools to support medical record clinical documentation including but not limited to forensic inpatient record assessment, analysis, and review; population of databases for statistical evaluation of same; coordinates future education projects; develops and implements plans for both formal and informal education of medical staff, nursing, and other clinical staff; identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation; facilitates multidisciplinary team in efforts for clinical documentation improvement.

Uses critical thinking, problem solving, deductive reasoning, analytical skills, writing and interpersonal skills in a dependable, self-directed and pleasant manner to achieve results while reviewing patient medical records.

Actively participates in team meetings and education of staff in the Clinical Documentation Management Program (CDMP) process.

Other duties as assigned.

Minimum Requirements:

• Three (3) or more years related experience
• Associate's Degree
• Registered Nurse (RN) License

Join us at Yuma Regional Medical Center dba Onvida Health

A career at Onvida Health is more than just a job. It’s a place to have a long and rewarding career, making a difference in the lives of those in our shared community. When you join our team, you become an integral part of a thriving community committed to improving the health and well-being of everyone in southwestern Arizona.

At Onvida Health, we believe in progress with purpose. Our commitment to innovation is matched by our dedication to kindness and integrity. We take our values seriously because we know they lead to better outcomes for our patients and a better experience for all of us. We’re looking for people who approach each day with a sense of possibility, a drive to make things better, and a commitment to kindness. If that sounds like you, you’re our kind of people.

If you’re looking for a career where innovation meets compassion, where you can grow and contribute to building a healthier tomorrow, Onvida Health is the place for you.

Life in Yuma, Arizona
Yuma, recognized by Guinness World Records as the Sunniest City on Earth, offers more than just sunshine. It’s a place where the great outdoors meets a welcoming, tight-knit community. Hike scenic trails, explore the Colorado River, or immerse yourself in local cultural festivals - all while embracing the beauty of this desert oasis. With easy access to larger cities and popular destinations, Yuma makes it easy to balance a fulfilling career with time for personal adventures and relaxation.

https://www.visityuma.com/

https://www.yumachamber.org/

Physical Requirements and working conditions for this position will be provided to you up on interview.