Clinical Documentation Specialist 2

About the role

The Clinical Documentation Integrity Specialist II at St. Charles Health System provides clinical based review and analysis of the documentation in the patient’s medical record to support accurate capture of patient’s complexity and severity of illness. Utilizes queries of the medical staff and other caregivers to clarify and support completeness of documentation.

Responsibilities

• Collaborates with physician, mid-level providers, ancillary staff, and medical records coders to identify principle and secondary diagnoses, and principle procedures. Also reviews for quality indicators.
• Maintains current knowledge of Medicare’s rules, regulations, and guidelines.
• Conducts initial and ongoing concurrent and some retrospective reviews for system wide admissions for all payors, initiates tracking process, and documents findings on EHR tracking system.
• Identifies when there is a need to clarify documentation in patient records and initiates queries or communication with providers to capture accurate documentation of the patient’s severity of illness and risk of mortality in compliance with all guidelines and requirements.
• Provides information and education as necessary to providers on an ongoing basis.
• Collaborates with Physician Advisor to present specialty specific and/or individual education.
• Independently attends provider service line meetings or team meetings to serve as a resource and/or educate on documentation opportunities.
• Volunteers for special projects in the department such as developing education materials/presentations, tip sheets, present teaching opportunities to co-workers, etc.
• Complies with all applicable laws, regulations, policies and procedures, supporting the health system’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violations of applicable rules, and cooperating fully with all company investigations and proceedings.
• Supports the vision, mission, and values of the organization in all respects.
• Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
• Provides and maintains a safe environment for caregivers, patients, and guests.
• Conducts all activities with the highest standards of professionalism and confidentiality.
• Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.
• Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient, and accurate.
• May perform additional duties of similar complexity within the organization, as required or assigned.

Requirements

• Education Required: As required by licensure for RN. Preferred: BSN
• Licensure/Certification/Registration Required: Current Oregon RN License. CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner).
• Experience Required: Minimum of two (2) years recent CDIS experience. Preferred: Proficient use of EPIC and 3M 360 Encompass software programs.