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Clinical Documentation Specialist Job

Cottage Health - RN Careers

Job Number: 18232

Facility: Santa Barbara Cottage Hospital

Location: Santa Barbara, CA

Shift: Days, Weekend Rotation

Schedule: FULL-TIME 8 HOUR (FP)

Hours: 7 - 3:30

Full Job Title: Clinical Documentation Specialist


Job Summary:
Provide concurrent review of clinical documentation in the medical record ensuring that the physician documentation supports the severity of patient illness and risk of mortality.

Major Accountabilities:
Provides concurrent review of the clinical documentation in the medical record; reviews the medical record with a clinical lens and identifies any missing or understated diagnoses. The key responsibility is to review the chart for information not currently in the chart but supported by clinical clues, then:

• Queries the medical staff when necessary by written and verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality.

• Performs a thorough chart review to determine the most appropriate principle diagnosis of the patient.

• Performs a thorough chart review to identify co-morbidities/complications and documents these appropriately within the concurrent CDS worksheet.

• Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality ratings/profiling purposes.

• Coordinates with coding/HIM/UR and other departments to ensure the coded record reflects the acuity of patients and level of provider care.

• Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization.

• Maintains the ability to be flexible and prioritizes daily responsibilities.


Requires:

Associate's degree in nursing; basic MS office skills; 2 years of clinical experience in an acute care setting and current California RN license.


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