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