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Clinical Documentation Specialist RN at Providence St. Joseph Health
Last updated: March 05, 2024
Job Listing
| Title | Clinical Documentation Specialist RN |
|---|---|
| Company | Providence St. Joseph Health |
| Location | Seattle, WA |
| Description |
Description Clinical Documentation Specialist RN Remote (Candidates must be located in Washington or Montana) Day Shift Monday - Friday 8 Hour Shifts 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 patients' true clinical picture within the medical record. Provider feedback is conveyed through attending and presenting at practice group meetings, medical directors and formal medical staff committees regarding the status and trends of the integrity of their documentation as needed. In partnering with the coding team, the CDS will be an expert with ICD-10, MS-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 care givers 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 profiling and reporting outcomes is complete and accurate. An additional goal will be to spend face-to-face time with the providers and quickly help/educate the providers understand their specific documentation trends as illustrated through ICD-10 assignment. 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, cranial (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 Swedish Shared Services 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. Completes initial medical records reviews of patient records within 24-48 hours of admission 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 critical to compliance with payor billing requirements; and (b) Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG or APR-DRG assignment upon patient discharge as needed. Is a positive contributor in how documentation will affect the 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. Performs medical record reviews, utilizing independent judgment and discretion to assign a working DRG and obtain appropriate clinical documentation through extensive review of CDI-related documentation areas; draft and submit compliance queries for follow up with providers; conduct follow up reviews of clinical documentation to ensure points of clarification with providers have been accurately recorded in the patients' medical record Collaborates with quality department to improve documentation for quality reporting and report on trends associated with documentation to ensure continued improvement Communicates with coders to identify root cause of CDI-Coder fina |
| Citation |
United States Department of Labor Employment and Training Administration (DOLETA) Minnesota Department of Employment & Economic Development (DEED)
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