Clinical Documentation Spec

About the Role

The Clinical Documentation Specialist is responsible for concurrent clinical documentation review with an emphasis on completeness and accuracy of provider documentation related to intensity of service required and severity of illness upon hospitalization and throughout patient stay. Initiates communication, verbal and written, with providers to facilitate clarification of need for greater specialty or completeness of the medical record. Provides formal education related to documentation integrity and completeness at medical staff department meetings and committees. Keeps physician leaders in areas of responsibility informed of pertinent data, documentation trends, and opportunities for learning and improvement related to documentation integrity.

Responsibilities

• Conduct concurrent clinical documentation reviews to ensure completeness and accuracy.
• Communicate verbally and in writing with providers to clarify documentation needs.
• Provide formal education on documentation integrity at medical staff meetings and committees.
• Inform physician leaders about documentation trends and improvement opportunities.
• Perform other duties as needed.

Requirements

• Bachelor's Degree in Nursing from an accredited school or Bachelor's Degree in Health Information Management (HIM) required. Bachelor's Degree in Nursing in progress acceptable with quarterly updates provided.
• Minimum three years of acute hospital nursing or acute hospital coding experience required.
• For nurses filling the role, one year of recent (within one year) acute care nursing experience required. Critical Care or ED experience preferred.
• For CDS members practicing in pediatric areas, minimum three years of pediatric acute hospital nursing experience required, PICU or NICU preferred.

Skills

• Recent experience as an acute hospital utilization reviewer or Case Manager with knowledge of third-party reimbursement requirements preferred.
• Able to read, write legibly, and speak in English with professional quality.
• Proficient in using computer and software programs necessary for the position.
• Able to relate and communicate positively, effectively, and professionally with others.
• Assertive and consistent in following or enforcing policies.
• Works calmly and responds courteously under pressure; leads, supervises, teaches, and collaborates.
• Able to communicate effectively in English in person, in writing, and on the telephone.
• Strong critical thinking and problem-solving skills.
• Works independently with minimal supervision; manages multiple assignments effectively.
• Performs basic math functions; organizes and prioritizes workload.
• Recalls information with accuracy; pays close attention to detail.
• Able to distinguish colors and smells as necessary for patient care.
• Hears sufficiently for general conversation in person and on the telephone.
• Identifies and distinguishes various sounds associated with the workplace or patient care.
• Sees adequately to read computer screens, medical records, and written documents necessary for the position.
• Discerns temperature variances through touch.

Licensures and Certifications

• California Registered Nurse (RN) License required for nurses filling the role.

About Us

Our mission is to continue the teaching and healing ministry of Jesus Christ. Our core values are compassion, excellence, humility, integrity, justice, teamwork, and wholeness.

Loma Linda University Health is a Seventh-day Adventist, faith and values-based Christian institution. Candidates must understand and embrace the mission, purpose, and identity of Loma Linda and its affiliated entities.