Santa Rosa, California

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What You Will Do

Manage the daily operations of the clinical documentation area.

Assumes responsibility and accountability for improving the overall quality and completeness of clinical documentation.  Promotes a partnership between the concurrent clinical reviewers, medical record coders, and physicians to improve documentation and reimbursement for WRMC.  Facilitates clarification and specificity to clinical documentation through appropriate interaction with physicians, advocating for appropriate reimbursement.  Supports the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes to reflect the patient’s true severity of illness, intensity of care, and risk of mortality.  Educates all members of the health care team on an ongoing basis.

• Current Florida RN license and/or RHIA, RHIT, CCS or CCA certification required; CDI experience preferred.
• Minimum of 2 years of experience in an acute care setting, (If RN, Critical Care, Medical/Surgical or Emergency department nursing preferred); unless being assigned to a specialty service line, then minimum of 3 years experience in that service line acceptable.

$90,000-$100,000

Description/Purpose of Position:
Provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality. Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.

Minimum Qualifications

Education:
Associates or Bachelor’s Degree in Nursing or Health Information Management

Experience:
Minimum of five (5) years of clinical experience in an acute care setting critical care, medical/surgical or Emergency Department nursing preferred. Or, minimum of five (5) years of coding experience in an acute care setting.

Technical Skills:
Computer proficiency to include word processing, databases, and spreadsheets. Familiarity with the operation of basic office equipment.

License/Certification:
Current RN license in the State of Nevada, or licensed RHIT or RHIA with CCS credential.

Other:
Knowledge of age-specific needs and elements of disease processes and related procedures required. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes. Working knowledge of inpatient admission criteria, Medicare reimbursement system and coding systems preferred, but not required. Must possess excellent written and verbal communication skills and critical thinking skills. Ability to work independently in a time oriented environment is essential.

• Challenging and rewarding work environment
• Growth and Development Opportunities
• Competitive Compensation
• Excellent Medical, Dental, Vision and Prescription Drug Plan
• 401k plan with company match

$90,000-$100,000

Responsible for preparing statistical reports, coding diseases and operations according to accepted classification systems and maintaining indices according to established policies and procedures.

• Graduation from high school or equivalent. Graduate as a Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Professional Coder (CPC), or a Certified Coding Specialist (CCS) from an approved program by the American Health Information Management Association (AHIMA)or the American Academy of Professional Coders (AAPC). Minimum of five (5) years direct work experience may be substituted for credentialing courses.

• RHIT, RHIA, CCS or CPC preferred.
• Minimum 2 years experience. Credentialed and have the ability to code either OP/ER/ASC and/or Inpatient charts; or, no credentials but has the ability to code both Inpatient, Outpatient, ER & ASC charts proficiently.
• Demonstrated knowledge of coding procedures, extensive reimbursement system knowledge, written and verbal communication skills. Candidate must possess knowledge of medical terminology, anatomy, physiology, and pathophysiology.

• Comprehensive medical, dental, life insurance, and disability plan options
• Pension Plan*/403(b) Plan
• 401(k) plan
• Tuition Assistance
• Health Care and Dependent Care Reimbursement Accounts
• On-Site Fitness Center (depending on location)
• Paid Time Off Program for vacation, holiday and sick time

D.O.E.

• Seeking nurses with extensive clinical experience and significant experience with clinical documentation improvement across the care continuum – inpatient, outpatient facility, and pro-fee. Candidates should have a track record of engaging successfully with physicians, working collaboratively with others, have a high level of subject matter proficiency, and have very good communication skills.

• Bachelor’s Degree – Nursing or equivalent field
• RN, MD
• CCDS/CDIP
• Ideal candidates have at least 10 years of clinical experience
• 2 years of experience in CDI and have a willingness to travel.

• Comprehensive medical, dental, life insurance, and disability plan options
• Full Relocation Assistance
• 401(k) plan
• Tuition Assistance
• Health Care and Dependent Care Reimbursement Accounts
• Paid Time Off Program for vacation, holiday and sick time

$120,000 - $150,000

Responsible for improving the overall quality and completeness of clinical documentation. This position analyzes medical records for DRG’s, complications, and comorbidities; identifies trends; and notes observations and recommendations for documentation improvement. This role also facilitates modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients. Additional duties include supporting the accuracy and completeness of the clinical information used for measuring and reporting physician and hospital outcomes and educating all members of the patient care team on an ongoing basis.

• Advanced degree can be in Nursing, Medicine, HIM/Coding or other related disciplines.
• Minimum of three years well-rounded medical/surgical acute care nursing or Medical Degree with two to three years demonstrating functioning as a physician or Certification Clinical Coder demonstrating a minimum of three years acute in-patient coding.
• Cert. Clinical Documentation Specialist(CCDS) or Cert. Documentation Improvement Practitioner(CDIP)

• Associate’s or Bachelor’s degree in Nursing; OR
• Medical School Graduate where Western Medicine is practiced

• RN – At least five (5) years of recent clinical experience caring for adults in an acute care hospital setting is required; coding and utilization review experience preferred
• Medical School Graduate – One (1) year of clinical experience preferred

• Advanced degree can be in Nursing, Medicine, HIM/Coding or other related disciplines.
• Minimum of three years well-rounded medical/surgical acute care nursing or Medical Degree with two to three years demonstrating functioning as a physician

• demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
• sufficient proficiency in speaking, reading, and writing the English language is necessary to perform the essential functions of this job, especially with the regard to activities impacting patient or safety or security
• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
• Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
• Demonstrates accountability and professional development
• Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
• Regular significant contacts with other personnel throughout the institution (including but not limited to – physicians and their staff, mid-level providers, mid-level staff, coders, Case Managers). Contacts may be in person, by telephone, or through correspondence. Requires assertiveness while being even tempered, with a pleasing personality and the ability to communicate easily with others.

$105,000 - $120,000

Responsible for the oversight of the JHH, JHBMC, HCGH, SBH, and SMH Clinical Documentation Excellence surgical service lines that will be comprised of over 15 Registered Nurses (RN) and/or Health Information Professionals. This role reports to the Clinical Documentation Excellence Director and works in collaboration with the Clinical Documentation Excellence Manager (Medical Service Lines) and CDE Educator. This role identifies opportunities to improve surgical clinical documentation quality thru process review, performance/quality, and productivity reporting, and works with VPMAs, Directors, and others to implement improved process and enhancements. The manager acts as a systems expert on matters related to physician clinical documentation, coding, and reimbursement processes in working towards agreed upon quality and productivity targets for all services in the health system. Works in collaboration with finance and quality staff along with leadership team and system hospital staff to support workflow and requirements that meet reporting, coverage, and quality review requirements. Works in collaboration with Clinicians, Quality Improvement/Assurance, JHHS HIM Coding, EPIC, data teams, 3M support teams, etc.

• Requires successful completion of an accredited program:a) requires Baccalaureate degree from an accredited School of Nursing, OR
  b) requires successful completion of an AMA approved Physician Assistant program, OR
  c) requires successful completion of the academic requirements or Health Information Technician – RHIT or Registered Health Information Administrator – RHIA certification accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).
• Master’s degree preferred.

• Bachelor’s degree in Nursing or graduate of a medical school with a medical doctorate degree from inside or outside the U.S
• At least 5 years of acute clinical experience. Critical care background preferred.
• Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting.
• Minimum of 2 years of experience as a clinical documentation specialist.
• CCS or Coding experience preferred.
• Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching.
• Knowledge of federal, state and private payer regulations.

• Requires comprehensive knowledge of anatomy, physiology, as defined by the Medical Diagnostic Categories and all body systems
• Strong background knowledge of disease process, pharmacology, and surgical techniques
• Requires college-level knowledge of Medical Terminology
• Requires a complete understanding of the unique functions of each clinical area
• Requires high level knowledge of ICD-10-CM, HCPCS, MHAC, AHRQ, APRDRG, DRG and other related classification systems as demonstrated by experience using such systems
• Requires strong understanding of HSCRC and CMI impact on hospital budget
• Requires knowledge of GBR, HSCRC and Medicare regulations, health care data infrastructure, and hospital organization.
• Requires experience in developing and presenting information to leadership level audiences, and coordination of staff in providing support services to clients in decentralized or consulting environments
• Work with finance department on continuous case mix modeling and assessment
• Track trends in documentation concerns and implementing corrective action
• Direct coding activities to ensure accurate, consistent and compliant coding for all services
• Create and update documentation tools on an ongoing basis
• Provide feedback to clinical documentation specialists, case managers, coders, physicians and other clinicians involved in the documentation improvement effort
• Recommend and implement corrective actions when deficiencies are identified
• Requires knowledge of clinical coding processing and documentation standards, guidelines, policies and procedures
• High level of proficiency in adult education and training
• Requires a understanding of Hospital bylaws and Joint Commission standards related to departmental activities
• Requires knowledge of clinical pertinence requirements and proficiency in abstraction and data entry into all of the data base systems used for clinical documentation
• Must be able to read and interpret electronic and manual documentation generated by healthcare professionals
• Must be proficient with the understanding of work flow in hospital facility coding
• Knowledge of Maryland Specific Quality measures required

• Ability to provide leadership and direction to CDE Staff in collaboration with CDE leadership team members
• Experience with 3M HIS products preferred
• Ability to analyze healthcare data required
• Robust interpersonal, communication (verbal, non-verbal, and listening) skills. Experience in developing and presenting education programs
• An understanding of adult learning theory and instructional design.
• Requires analytical ability in order to complete tasks assigned, gather and interpret data from different courses, and resolve problems
• Must be able to read and understand coding guidelines. Must be able to maintain patient confidentiality
• Strong interpersonal and communication skills are required as is knowledge of available information resources and tools
• Independent and professional judgment is required to design and develop innovative workflow techniques structure and strategies regarding quality improvement for the health system
• Ability to productively interact with all areas of the health system to ensure maximum revenue generation
• Ability to successfully manage, recruit, and develop a strong team to support the revenue and regulatory initiatives of JHHS
• Must be proficient with Outlook, Microsoft Word, Excel , and Power Point
• Comprehensive experience with Epic and Tableau preferred

1. RN: Must possess current licensure to practice as RN in State of Maryland or another state that participates in the Nurse Licensure Compact.

PA: Must possess current licensure to practice as a PA by the Maryland Board of Physicians. Board certified by the National Commission on Certification of Physician Assistants (NCCPA).

RHIT/RHIA: Must possess clinical documentation certification through the Association of Clinical Documentation Improvement Specialists (ACDIS) and/or American Health Information Management Association (AHIMA) and be a Certified Coding Specialist (CCS).

1. Certified Clinical Documentation Specialist (CCDS) obtained through the Association of Clinical Documentation Improvement Specialists (ACDIS) and/or Certified Documentation Improvement Practitioner (CDIP) obtained through the American Health Information Management Association (AHIMA).

6 years of experience in the field of quality improvement, medical record/health information administration, acute care, clinical documentation and/or coding preferred. 1 year of staff management experience required at minimum if past experience is complemented by experience in inpatient, outpatient, compliance, medical necessity, charge master coding quality improvement, or surgical clinical documentation improvement.

• 4 years in clinical documentation strongly preferred
• Be familiar with all government health care reimbursement systems
• Familiarity with Quality Programs
• Coding experience preferred

$120,000-$140,000

Summary:
The Clinical Documentation Specialist demonstrates excellent customer service performance in that his/her attitude and actions are at all times consistent with the standards contained in the Vision, Mission and Values of HealthCare and the commitment to Extraordinary Care for Every Generation. This nurse is responsible for concurrent review of the clinical documentation in the medical record to facilitate appropriate physician documentation to accurately reflect patient severity of illness, risk of mortality, and DRG assignment. This nurse is accountable for meeting case mix goals, which translate into financial targets, and severity of illness, risk of mortality, and quality indicator goals, which impact hospital and physician profiling.

Responsibilities:
Demonstrates excellent customer service.
Contributes to organization success targets for patient satisfaction by meeting the Case Coordinator Expectations for Customer Satisfaction.
Contributes to organization success targets for net operating margin.
Ensures the availability of accurate and timely information.

In collaboration with the physician, identifies principal and secondary diagnoses and procedures, and assigns a working DRG. Identifies options and relative weights when more than one diagnosis may be assigned as principal. Performs a thorough chart review to identify complications and comorbid conditions.
Conducts the initial concurrent review process for all selected admissions to initiate the tracking process and documents findings on the DRG worksheet.
Demonstrates an understanding of the importance of and makes an effort to capture ALL potential secondary diagnoses for profiling purposes.
Screens record for key quality indicators and concurrently addresses issues with physicians
Appropriately and assertively communicates with finesse concurrently with physicians when requesting clarification or documentation for severity of illness, risk of mortality, DRG assignment, or quality indicator.
Utilizes tools available to educate physicians as to clinical documentation.

Utilizes monitoring tools to track the progress of the DRG Assurance program, interprets tracking information, and develops and implements action plans for improvement.
Assists in the development and distribution of APR/DRG physician profiling reports.
Develops tracking reports to demonstrate effectiveness of program, analyzes findings, develops and implements action plans. Prepares administrative reports for presentation to Executives. Maintains accountability for meeting goals.
Analyzes data reports to identify deficiencies in own practice, and actively seeks education to improve. Collaborates with HIM coders in this process.
Analyzes data reports to identify patterns by physician or patient population, and targets action plans to resolve issues.

Plays an active role in developing and delivering education to physicians specific to documentation challenges.
Coordinates and facilitates communications between coders and payers/review agencies. Reviews DRG changes requested by payers and collaborates with coders in constructing appeals.

Demonstrates excellent communication skills, negotiation skills, diplomacy, finesse and assertiveness.
Builds and nurtures professional, effective relationships with all members of the Healthcare team, particularly physicians.
Manages conflict effectively, striving for win-win outcomes.
Maintains complete confidentiality of patient information, in addition to hospital and individual practice pattern data.

Other information:

EDUCATION/EXPERIENCE
Education/Licensure/Certification Required:
RN with current license in State of Michigan.
Bachelor’s degree or willingness to complete within three years

Would consider a foreign national with an MD degree and CCDS certification.
Experience preferred/required:
Minimum of 5 years clinical experience in an acute care setting required.
Case management, ICU, CCU, or Med Surg experience strongly preferred

KNOWLEDGE/SKILLS/ABILITIES
Knowledge of care delivery documentation systems and related medical record documents.
Knowledge of age-specific needs and the elements of disease process and related procedures.
Excellent communication and critical thinking skills.
Working knowledge of Medicare reimbursement and coding structures.
Ability to work independently in a time oriented environment.
May be exposed to all patient elements, e.g. blood borne pathogens, and to environmental hazards such as anesthetic gases or elements.
Demonstrates good computer skills.

$75,000-$85,000

IPosition Summary:

The Clinical Documentation Improvement Specialist is a professional nurse accountable for the documentation management of a group of patients. The clinical documentation specialist focuses on safe effective patient care, customer satisfaction and quality outcomes. They are responsible for assisting in maintaining a financially stable department, promoting their own development with an emphasis on evidence based practice and education supported by a Practice Governance framework. Upon admission and concurrently throughout the inpatient stay, the clinical documentation specialist reviews the medical record for documentation that is ambiguous or nonspecific. The clinical documentation specialist proactively engages the physician in discussion to clarify documentation to ensure the inpatient medical record accurately reflects the patient’s severity of illness and the intensity of services provided. The clinical documentation specialist collaborates in the application of Core Measures to manage the care of targeted diagnoses within the system’s primary service lines.

• Upon admission reviews inpatient records of patients with Medicare and priority managed care payers and assigns working MS-DRG.
• Reviews the medical record for documentation that is ambiguous or non-specific and appropriately queries the physician or physician extender.
• Proactively seeks clarification from the physician or physician extender to ensure that the medical record reflects the patient’s severity of illness and intensity of service.
• Recognizes target MS-DRGs commonly associated with clarification opportunities.

• Three years in a critical care or medical surgical hospital setting
• One year in case management and/or clinical documentation management. (Desired)
• RN required or medical equivalent degree
• CCDS preferred

$85,000-$95,000

The RN Documentation Specialist II demonstrates expert knowledge of documentation
principles and is responsible for improving the overall quality and completeness of
clinical documentation.
Facilitates modifications to clinical documentation through interaction with physicians,
nursing staff, other patient care givers, and Health Information Management (HIM)
coding staff to ensure that documentation accurately reflects each patient’s severity of
illness.
Ensures accuracy and completeness of clinical information used for measuring and
reporting physician and hospital outcomes and educates all members of the patient care
team on an ongoing basis.

Specific Responsibilities:
Demonstrates expert knowledge of DRG payor issues, documentation requirements and
strategies, as well as policies and procedures.
Improves the overall quality and completeness of clinical documentation by performing
initial and continued stay reviews using clinical documentation guidelines.
Participates in the identification of quality indicators (PSIs, HACs)
Provides ongoing communication with coders, auditors, care managers, nurses, and/or
physicians to assure that documentation reflects the care and services provided.
Documents actions in the CDI software (3M 360) and conducts follow-up reviews of
clinical documentation
Processes discharges by updating the appropriate 3M 360 screens to reflect any
changes in status, conferring with physicians to finalize diagnoses and assisting HIM in
resolving post discharge queries.

Serves as a resource and educates all internal customers on clinical documentation
opportunities, coding and reimbursement issues, as well as performance improvement
methodologies.
Facilitates problem solving, education, and discussion at CDI meetings and training
sessions.
and provides team and department support.

Qualifications:
Illinois RN license
BSN or MSN required.
Minimum of 3-5 years clinical nursing experience preferred. Critical Care and/or ED
experience preferred.
At least 1-2 years Clinical Document Specialist experience required.
Certification in clinical documentation improvement required within 1 year.
Ability to demonstrate expert Clinical Documentation Specialist and coding knowledge.
Excellent interpersonal communication skills, ability to work collaboratively with all
members of the health care team.
Ability to travel throughout the Medical Center and maintain multi-unit assignment.
Computer skills and the willingness to learn CDI software is required.

$90,000 - $100,000

Position Summary:

Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses or procedures.

Essential Functions:

-Conducts initial and follow-up concurrent reviews on targeted admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care.

-Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided.

-Review medical record concurrently for documentation not yet in the record but supported by clinical indicators.

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

-Determines the appropriate principle diagnosis of the patient.

-Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.

-Documents findings in workflow tools, noting all key information used in the tracking process.

-Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record.

-Uses appropriate querying tools (templates) to capture needed documentation.

-Queries the medical staff when necessary by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan.

-Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or on individually with physicians.

-Reviews the progress of the CDI program by interpreting performance, process, and quality ratings reports.

-Able to identify areas of focus through report analysis.

-Maintains reasonably regular, punctual attendance consistent with policies, the ADA, FMLA and other federal, state and local standards.

-Maintains compliance with all policies and procedures.

Other related functions:

-Maintains established work production standards.

-Assumes the responsibility for professional growth and development.

-Ability to work independently in a time-oriented environment.

Education/Training:

-Graduate from an approved school of nursing.

Licensure/Certification:

-Must maintain current Registered Nurse (RN) license in the State of Florida.

Experience:

-Five (5) years acute care hospital experience required.

-Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting.

-Knowledge of age-specific patient needs and the elements of disease processes and related procedures.

-Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.

$70,000 - $80,000

We are seeking an experienced nurse for our clinical documentation improvement program. Clinical Documentation Specialists (CDSs) work collaboratively with physicians, nursing staff, clinical caregivers, and coding staff to assure accurate and complete documentation in the medical record. Through concurrent chart reviews CDSs use compliant processes to support the appropriate severity of illness, expected risk of mortality, complexity of care for each individual patient, and other documentation that results in high quality performance and appropriate reimbursement. CDSs provide on-going education to physicians both one on one, in groups, and by educational tools.

Clinical Documentation Specialists adhere to departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance. Actively participates in outstanding customer service.

Qualifications

• Graduate from an accredited school of nursing required. Bachelor’s degree preferred.
• Three years related clinical experience in an acute care setting required. Experience interacting with physicians required. ICD-10 coding and DRG experience a plus.
• Requires current licensure as a Registered Nurse in the state of Washington.

Highlights of the CDI Program
• Amazing support from administration
• Flexible work schedule
• Engaged Physician Advisor
• Escalation process in place

Benefits

• Free public transportation pass
• Competitive compensation package
• Generous PTO
• Medical, dental, vision
• 2 part retirement plan including matching
• Long term disability
• Flex spending
• Extended illness banked hours
• Free parking
• Employee Assistance program
• Professional development

Just a few of our employee perks

• Cell phone plan discounts
• Discounted Mariners and Sounders tickets
• Computer discounts
• Discounted lift tickets
• Discounted movie tickets
• Discounted gym memberships
• Free Seattle Art Museum passes

$95,000 - $105,000 + Relocation Assistance

Facilitates the improvement in the overall quality and completeness of concurrent medical record documentation to help achieve accurate inpatient coding, APR-DGR assignment, severity level and reimbursement. Obtains appropriate documentation through interactions with physicians and staff. Educates members of the patient care team on documentation guidelines.

COMPENTENCIES
Education:
Requires either successful completion of a RN program, successful completion of an AMA approved Physician Assistant program or successful completion of the academic requirements, at the baccalaureate level (RHIA), of an HIM program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).

Knowledge:
Requires excellent and comprehensive knowledge of anatomy, physiology, as defined by the Medical Diagnostic Categories and all body systems. Strong background knowledge of disease process, pharmacology.
Requires college-level knowledge of Medical Terminology.
Requires a complete and thorough understanding of the unique functions of each clinical area.
Must be conversent in: ICD-9-CM, APRDRGs, DRGs
Must be proficient with Microsoft Word, Excel, and Power Point. Knowledge of Access, knowledge of other programming languages a plus.
Requires in-depth knowledge of clinical coding processing and documentation standards, guidelines, policies and procedures.
Must be conversant in clinical documentation improvement.
High level of proficiency in adult education and training
Requires a thorough understanding of Hospital bylaws and Joint Commission standards related to departmental activities.
Requires knowledge of clinical pertinence requirements and proficiency in abstraction and data entry into all of the data base systems used for clinical documentation.
Must be able to read and interpret electronic and manual documentation generated by healthcare professionals.
Requires understanding of HSCRC and CMI impact on hospital budget.

Skills:
Strong interpersonal, communication (verbal, non-verbal, and listening) skills. Experience in developing and presenting education programs.
An understanding of adult learning theory and instructional design.
Competent computer skills including word processing, spreadsheets, presentation software.
Analytical skills.

Required Licensure Certification:
RN: Must possess current licensure to practice as RN in State of Maryland or another state that participates in the Nurse Licensure Compact.
PA: Must possess current licensure to practice as a PA by the Maryland Board of Physicians. Board certified by the National Commission on Certification of Physician Assistants (NCCPA).
RHIA: Must possess certification through the Association of Clinical Documentation Improvement Specialists (ACDIS) or be a Certified Coding Specialist (CCS).

Work Experience:
RN : Requires a minimum of 3 years registered nurse clinical experience in similarly complex acute care setting. Familiarity with utilization review, case management, nurse review activities or coding experience preferred.
PA: Requires a minimum of 3 years as a Physician’s Assistant in a similarly complex acute care setting.
RHIA: Requires minimum 3 years of previous APR-DRG validation experience and 5 years of coding and clinical documentation experience with extensive clinical knowledge in an acute hospital environment.

$80,000 - $105,000

Provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality. Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.

Description/Purpose of Position:
Provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality. Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.

Minimum Qualifications

Education:
Associates or Bachelor’s Degree in Nursing or Health Information Management

Experience:
Minimum of five (5) years of clinical experience in an acute care setting critical care, medical/surgical or Emergency Department nursing preferred. Or, minimum of five (5) years of coding experience in an acute care setting.

Technical Skills:
Computer proficiency to include word processing, databases, and spreadsheets. Familiarity with the operation of basic office equipment.

License/Certification:
Current RN license in the State of Nevada, or licensed RHIT or RHIA with CCS credential.

Other:
Knowledge of age-specific needs and elements of disease processes and related procedures required. Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes. Working knowledge of inpatient admission criteria, Medicare reimbursement system and coding systems preferred, but not required. Must possess excellent written and verbal communication skills and critical thinking skills. Ability to work independently in a time oriented environment is essential.

$80,000 - $100,000

EXPERIENCE AND EDUCATION

5 years nursing experience in an acute care Hospital setting, preferred in critical care; and 3 years experience working in a Clinical Documentation Integrity program. RN required; with BSN preferred; and with a (CCDS) Certified Clinical Documentation Specialist, or (CDIP) Certified Documentation Improvement Practitioner, or must attain CCDS or CDIP within 6 months in position. Current TX RN license; current CPR certificationRN, BSN; or RN with 6 years of clinical experience and UR experience; OR RN, CCM with 4 years experience in related field.

JOB DUTIES

1. Facilitates appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record to improve overall quality and completeness of clinical documentation.

2. Communicates effectively (face-to-face) with Physicians, the Healthcare Team, and Multidisciplinary Teams to ensure accurate and complete documentation of all relevant diagnoses, procedures and treatments. Provides education on clinical documentation opportunities to support acuity, quality, and coding.

3. Initiates Physician Queries for clarification and specificity as appropriate, following established query guidelines for compliant queries. Performs follow-ups to ensure clarification was documented prior to discharge.

4. Performs follow-up reviews and updates CDI/DRG worksheet to reflect changes in patient status, to verify the most appropriate Prin Dx and DRG and validate supporting documentation.

5. Works collaboratively with the Coding and Quality Teams to ensure the clinical documentation fills the ‘gaps’ between clinical and coding language.

6. Maintains an expert level of knowledge of CDI related practice and performance.

$70,000 - $90,000 DOE

The Clinical Documentation Specialist will provide active, concurrent and retrospective review of provider documentation, query for clarification, provide feedback, and educate clinical care providers to improve the documentation of all conditions, treatments and care plans within the health record to accurately reflect the condition of the patient and promote patient care. In addition, the CDS will work with the physicians to ensure high quality documentation that supports accurate representation of the care provided to the patient as reflected through MS-DRG assignment, case mix index, severity of illness, risk of mortality, quality measures, physician profiling, hospital profiling and reimbursement rules.

The CDS exhibits a comprehensive knowledge of clinical documentation requirements, DRG assignment, clinical conditions or procedures, and understanding of coding concepts and guidelines. The CDS is also responsible for communicating and educating members of the patients care team regarding documentation guidelines; and collaborating with other stakeholders, including Quality; Enterprise Coding; and Integrity.

Work Schedule, Hours, FTE, Salary Range
****This position is subject to a collective bargaining agreement with the Oregon Nurses Association (ONA)****

This is a full time (1.0 FTE) position. Schedule will be Monday through Friday from 8:00 AM to 4:30 PM with possible weekends. Salary is based on the ONA contract. This position is located in downtown Portland. We are hiring 4 applicants for this position.

Functions/Duties of Position
The Clinical registered nurse (RN) provides compassionate, evidence-based, and efficient care to individuals, families, communities and patient populations. The Clinical RN’s care delivery is consistent with the Oregon Nurse Practice Act, the ANA Scope and Standards of Practice, and the ANA Code of Ethics. The Clinical RN demonstrates the professional role obligations of scientist, leader, practitioner, and knowledge transferor [O’Rourke Model of the Professional Role™]. Professional accountability enriches the Clinical RN’s engagement as a leader in promoting an inter-professional culture of collaborative decision-making, innovation, life-long learning, and teamwork. The Clinical Nurse exemplifies the principles of a Culture of Safety by committing to a Just Culture, a Reporting Culture, Learning Culture, and an Engaged Informed Culture.

Job Requirements

REQUIRED:

· External applicants- BSN required;
· Current OHSU employees-BSN preferred;
· Training in Clinical Documentation Improvement through ACDIS or AHIMA;
· Certified Clinical Documentation Specialist (CCDS or CDIP); or certification within 6 months of hire
· Minimum of 3-5 years of experience in acute care nursing (RN); at least 1 year of experience in a Clinical Documentation Integrity program.
· Excellent observation skills, analytical and critical thinking, problem solving with good verbal and written communication skills.
· Knowledge of age specific needs and the elements of disease processes and related procedures for the targeted patient population.
· Clinical knowledge and understanding of pathology/physiology of disease processes.
· Strong understanding of reimbursement and coding methodologies and guidelines; MS-DRGs; Severity of Illness, Risk of Mortality, Medical Necessity, Core and Quality Measures and impact of Length of Stay.
· Strong understanding of medical terminology.
· Ability to work independently in time sensitive environment.
· Ability to work as a part of a multidisciplinary team.
· Ability to assess, evaluate and teach key concepts related to documentation improvement.
· Time management and project Management skills.
· Proficiency in computer use and windows based applications.
· Current unencumbered Oregon RN.
· Valid Basic Life Support (BLS) certification issued by American Heart Association; Certified Clinical Documentation Specialist (CCDS or CDIP); or certification within 6 months of hire.

PREFERRED:

2-3 years of experience in a Clinical Documentation Integrity program with experience in clinical quality, utilization management, case management, or related field.
Additional Details
WORKING CONDITIONS:

Flexible schedule – may include rotating weekends

Equal opportunity, affirmative action institution. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or protected veteran status. Applicants with disabilities can request reasonable accommodation by contacting the Affirmative Action and Equal Opportunity Department at 503-494-51

$80,000 - $100,000

You will be responsible for:

• Demonstrates, through behavior, Integrity, Compassion, Balance, Excellence, Stewardship, and Teamwork
• Reviews concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies.
• Completes accurate and timely record review to ensure the integrity of documentation compliance.  Completes accurate and concise input of data into CDMP Trak resulting in accurate metrics provided by the CDMP program.  Understands and supports CDMP documentation strategies (upon completion of training) and continues to educate self and team members using educational tools, videos and provided WebEx’s.
• Recognizes opportunities for documentation improvement using strong critical-thinking skills.  Uses critical thinking and sound judgment in decision making keeping reimbursement considerations in balance with regulatory compliance.  Initiates/formulates CDMP severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other medical staff.
• Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs and HACs to ensure documentation compliance is accomplished.
• Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including attending physicians, allied health practitioners, nursing, and care management.  This includes quarterly compliance updates from Medicare.
• Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation.  Communicates with HIM staff and collaborates with them to resolves discrepancies with DRG assignments and other coding issues.
• Completes well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications
• Participates in Task Force meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI group.
• Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.
• Performs other duties as assigned.

What will you need?

• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrate excellent physician relations.
• Able to organize and present information clearly and concisely; excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills.
• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist
• Dependable, self-motivated and pleasant
• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills
• Knowledge of pathophysiology, disease processes and treatments
• Knowledge of regulatory environment
• Strong ability to organize/triage work and manage multiple priorities at once
• Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience
• Current active State license as a Registered Nurse, Nurse Practitioner, or Physician’s Assistant.
• Adventist Health Care online learning
• Achieve a 70% or greater on JA Thomas Clinical Competency Pre-Assessment.
• Knowledge of clinical documentation requirements that identify clinical conditions or procedures (Preferred)
• Coding background (Preferred)
• BSN, MSN (Preferred)
• Clinical Documentation Specialist experience(Preferred)
• CCDS (Certified Clinical Documentation Specialist) certification (Preferred)

$70,000 - $80,000

Clinical Documentation Analysts improve overall quality and completeness of the medical record. Through concurrent interaction with physicians, nursing staff, case management and medical records coding staff/compliance specialists, they facilitate modifications to clinical documentation to ensure accurate depiction of the level of clinical services, reason for admission, patient severity, risk of mortality and conditions present on admission. Reviews quality of medical record documentation and conveys deficiencies to house staff and attending physician. Compiles and documents chart findings in dedicated CDI database on a daily basis. Communicates with and educates members of the patient care team (physicians, advanced practice providers, patient resource managers, and case management) on an ongoing basis. Participates in select committees and provides education programs as necessary.

Reviews clinical documentation and facilitates modifications, as needed, to ensure that documentation accurately reflects the reason for admission, intensity of service rendered, risk of mortality, and conditions present on admission for all patients, in compliance with government and other regulations.

Maintains a system to identify admissions for chart review

Initiates chart review within 48-72 hours of identification.

Monitors the reviewed medical record every 48 hours to determine compliance to established documentation standards.

Notifies the attending physician and house staff officers or other disciplines promptly of chart deficiencies requiring clarification, with a preference for face-to-face communication when practical.

Conducts follow-up reviews to ensure points of clarification have been addressed/recorded in the medical record and maintains an ongoing record of the results of each chart review including responses to each intervention

Serves as resource to physicians and other members of the healthcare team in matters relating to published DRG, SOI/ROM, ICD-9, ICD-10 and PCS information.

Maintains a level of practice demonstrating knowledge and understanding of AHIMA Practice Brief and knowledge of compliance and regulatory agency expectations.

Compiles and provides timely entry to CDI database for statistical reporting.

BSN or PA (Physician’s Assistant) or NP (Nurse Practitioner) or
Doctorate degree in a medically related field required.
Experience

3 years of relevant experience
Degrees, Licensures, Certifications

Current licensure as an RN, NP, PA or licensure in the specific medical field associated with a Doctorate degree.

CCDS, CCS, or CDIP certification preferred.

Excellent support from Administration

Fully electronic medical record (EPIC)

Collaborative and innovative environment

$70,000 - $85,000

Senior Level individual would manage CDI engagements with heavy involvement and role in overall client interaction and satisfaction. Responsible for overall delivery, education and training, and client support. Responsible for defining and shaping the services for each client and for changing rules and regulations. Manage multiple engagements with strong project management skills. Assist in the marketing and sales of CDI services through client presentations and discussions. Must have deep understanding and knowledge of clinical documentation improvement services with prior training experience strongly preferred.

healthcare setting with focus on documentation improvement and relative issues is strongly preferred

• Demonstrated written and verbal communication skills and the ability to manage and prioritize multiple projects
• Demonstrated ability to work independently, exercise good judgment, and be resourceful
• Demonstrated ability for developing strong working relationships with key stakeholders and/or clients
• Experience in assigning ICD-9 codes, CPT codes, and identifying medical necessity is preferred
• Experience/knowledge of regulatory compliance issues facing the healthcare industry is a plus
• Ability to travel regularly for project assignments is required

Great benefit package and bonus incentives. Salary open based on individual with expected base salary range of $100K – $170K plus bonus incentives. Position requires at least 70% travel to client sites, sales meetings, and regional/national conferences.

$100,000 - $150,000

Senior Level individual would manage CDI engagements with heavy involvement and role in overall client interaction and satisfaction. Responsible for overall delivery, education and training, and client support. Responsible for defining and shaping the services for each client and for changing rules and regulations. Manage multiple engagements with strong project management skills. Assist in the marketing and sales of CDI services through client presentations and discussions. Must have deep understanding and knowledge of clinical documentation improvement services with prior training experience strongly preferred.

• One of the following credentials: RN, MD, RHIT, CCS, CCDS, ICD-10 Certified a plus
  
  • BSN, BA, MBA, MA or MS from an accredited college/university is desired
  • Three or more years of experience in a professional services setting or

healthcare setting with focus on documentation improvement and relative issues is strongly preferred

• Demonstrated written and verbal communication skills and the ability to manage and prioritize multiple projects
• Demonstrated ability to work independently, exercise good judgment, and be resourceful
• Demonstrated ability for developing strong working relationships with key stakeholders and/or clients
• Experience in assigning ICD-9 codes, CPT codes, and identifying medical necessity is preferred
• Experience/knowledge of regulatory compliance issues facing the healthcare industry is a plus
• Ability to travel regularly for project assignments is required

Great benefit package and bonus incentives. Salary open based on individual with expected base salary range of $100K – $160K plus bonus incentives. Position requires at least 70% travel to client sites, sales meetings, and regional/national conferences.

$100,000 - $150,000