Clinical Documentation Specialist-RN

About the role

The Clinical Documentation Specialist RN position at St. Luke's Health - Patients Medical Center is responsible for facilitating accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the CDMP process is a key role.

Responsibilities

• Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies
• Accurate and timely record review
• Recognize opportunities for documentation improvement
• Formulate clinically credible documentation clarifications
• Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety

Requirements

• Current Registered Nurse (RN) license that allows you to practice in our state
• Graduate of an accredited nursing program
• Five (5) years of adult acute care experience in med/surg, critical care, emergency room, or PACU
• High school diploma or GED

Qualifications

To be successful in this position, you will:

• Be responsible and compassionate
• Display excellent verbal and written communication and interpersonal skills
• Be able to work independently with minimal supervision
• Be able to effectively educate patients and their families on the in-home healthcare process

Skills

Not specified

Benefits

Not specified

Pay

$39.18 - $52.00/hour

Schedule

80 hours per pay period, 8:00 am - 5:00 pm, Day shift, No remote work, No travel

Category

Risk and Compliance