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Clinical Documentation Specialist RN at Providence St. Joseph Health

Last updated: March 22, 2024

Job Listing

Title Clinical Documentation Specialist RN
Company Providence St. Joseph Health
Location Everett, WA
Description Description
Clinical Documentation Specialist RN
Remote (Candidates must reside in Washington State)
Full Time (40 Hour Week)
Day Shift
8 Hour Days
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.
Providence Regional Medical Center Everett received the HealthGrades Distinguished Hospital Award for Clinical Excellence four years in a row.
Completes reviews of patient records for assigned patient population to: (a) independently evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG or APR-DRG assignment in compliance with coding guidelines and regulatory requirements; and (b) Conducts follow-up reviews of patients to support and assign a working or final MS-DRG or APR-DRG assignment.
Contributes to accuracy of Hospital Value-Based Purchasing (VBP) results, how patients are included in the Potentially Preventable Readmissions (PPR), and to identify those conditions that may be Hospital Acquired Conditions (HAC), Patient Safety Indicators (PSI), accuracy of Present on Admission (POA) conditions, and penalties will be associated with lack of proper documentation.
Drafts and submits compliant queries to providers in compliance with industry compliance standards; conducts follow up reviews of clinical documentation to ensure points of clarification with providers have been accurately recorded in the patient's medical record.
Ability to reconcile reviewed cases with final coding and communication with coders to identify root cause of CDI-Coder final DRG mismatch and resolution of incongruence as part of ongoing quality control efforts.
Meets and exceeds established productivity guidelines as well as additional key performance indicators such as review rates, query rates, agreement rates, etc.
Validates documented clinical conditions in the medical record.
Follows queries through to completion.
Contributes to development of new caregivers.
Maintains flexibility in work assignments based on organizational business need.
Stays current with AHA Official Coding and reporting Guidelines, CMS and other agency directives for ICD-10-CM coding. Attends any required CDI and/or coding education as
Citation United States Department of Labor Employment and Training Administration (DOLETA)
Minnesota Department of Employment & Economic Development (DEED)
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