Clinical Documentation Specialist Details

Clinical Documentation Specialist

San Juan Regional Medical Center - Farmington, NM

Employment Type : Full-Time

Facilitates improvement in the quality and completeness of patient records on a concurrent basis, using a multi-disciplinary process. Applies clinical knowledge and coding knowledge to evaluate clinical indicators, diagnoses, and treatment plan for assigned inpatients, to identify gaps in physician documentation

Required__ Behaviors:

• As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization: Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.

Required Qualifications: **

Registered Nurse - Minimum of 3 years strong clinical background in acute care. Current NM Licensure

Excellent written and verbal communication skills

Analytical thinking skills

Team-oriented

Basic computer skills

Highly-organized

Preferred Qualifications: **

BSN

Certified Clinical Documentation Specialist (CCDS)

Coding experience

Duties and Responsibilities**:

1. Comprehensively reviews patient records, concurrently and retrospectively, to assure a complete and accurate representation

of the severity of illness and use of resources.

2. Assigns Working DRG

3. Works closely with physicians, Case Management staff, and Coding to review documentation coding practices analyzing

whether documentation supports the acuity of the patients.

4. Identifies gaps in physician documentation and facilitates appropriate documentation improvement interventions with

physicians.

5. Identifies Clinical Documentation Improvement (CDI) best practices, benchmarks and improvement strategies to augment

compliance objectives.

6. Stays current on information pertaining to coding, compliance, clinical guidelines and payer requirements as it relates to MSDRG

assignment, documentation and other payment requirements.

7. Each employee is responsible for implementing SJRMC’s Service Standards into their daily work.

Safety, Courtesy, Effectiveness, and Stewardship

8. Other duties as assigned

Physical Demands and Environmental Work Conditions**:

• Prolonged standing/sitting/walking

• Fast paced environment

• High level of activity with many interruptions

• Possible exposure to communicable disease

• Repetitive motions, ie: keyboard usage

Sensory Requirements:

The employee will need to be able to hear:

• Alarms on equipment/fire alarms/overhead announcements

• Patients/family/physician verbal discussion

• Feedback from other healthcare providers

The employee will need to be able to see:

• Focus on close-up and distant objects

• Have intact: peripheral vision and depth perception

San Juan Regional Medical Center provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Physical Setting:

• Acute care
• Hospital

Schedule:

• Day shift

Ability to commute/relocate:

• Farmington, NM 87401: Reliably commute or planning to relocate before starting work (Preferred)

Experience:

• Acute care: 3 years (Preferred)

License/Certification:

• RN (Preferred)

Work Location: One location