Clinical Documentation Specialist (2026-0294)

Responsibilities

• Reviews EMR for completeness and accuracy for severity of illness and quality using the documentation strategies.
• Accurately and timely record review.
• Recognize opportunities for documentation improvement.
• Initiates severity worksheet for inpatients.
• Formulate clinically credible documentation clarifications.
• Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety.
• Effective and appropriate communication with physicians.
• Timely follow up on all cases and resolution of those with clinical documentation clarifications.
• Communicates with HIM staff and resolves discrepancies.
• Accurate input of data for reconciliation of case.
• Provides necessary information and education to physicians and staff to facilitate the appropriate documentation goals.
• Identifies any barriers to completion of documentation goals with appropriate interventions.
• Reviews of regulations and coding guidelines through seminars, meetings, and materials.
• In cooperation with the director of PFS/HIM, presents education sessions to physicians and other VMC providers regarding documentation regulations and chart audit findings.
• Maintains confidentiality of all accessible patient financial or medical records information.
• Demonstrates the awareness of the importance of cost containment for the department.
• Provides suggestions regarding process or quality improvement opportunities to department manager.

Qualifications

• Current unrestricted WA State Registered Nurse license.
• Bachelor's degree in Nursing, preferred.
• Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review.
• Pass a pre-hire Clinical Exam with a minimum score of 70%.
• Effective communication with Providers.
• Knowledge of hospital clinical practice standards for physicians and other health care providers.
• Knowledge of ancillary service departments, quality control and safety standards.
• Critical thinking, problem solving and deductive reasoning skills.
• Familiarity with health care audit and research design.
• Knowledge of Pathophysiology and Disease process.
• Functional knowledge of DRG coding systems.
• Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.
• Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.
• Meet productivity guidelines.
• Ability to learn/develop the skills necessary to perform and meet goal standards.
• Organizational, analytical, writing, and interpersonal skills.
• Dependable, self-directed, and pleasant.
• Critical thinking, problem solving and deductive reasoning skills.
• Knowledge of Pathophysiology and Disease Process.
• Basic Computer skills - familiarity with Windows based software programs.
• Knowledge of regulatory environment.
• Understand and support documentation strategies (upon completion of training).
• Knowledge of Core Measure and Patient Safety Indicators (upon completion of training).