Clinical Documentation Specialist RN

Description

Clinical Documentation Specialist RN

Remote (Candidates must be located in Washington or Montana)

Day Shift

Monday - Friday

8 Hour Shifts

The Clinical Documentation Specialist (CDS) is responsible for supporting and facilitating the overall quality of medical record documentation by improving the completeness, accuracy, and reliability of clinical documentation. A key success factor of this process is educating providers through the query process and independently supporting them with education and feedback to accurately reflect the patients' true clinical picture within the medical record. Provider feedback is conveyed through attending and presenting at practice group meetings, medical directors and formal medical staff committees regarding the status and trends of the integrity of their documentation as needed. In partnering with the coding team, the CDS will be an expert with ICD-10, MS-DRG and APR-DRG assignment.

The CDS's primary responsibility will be to obtain appropriate clinical documentation through extensive review of provider, nursing, ancillary, and other patient care givers documentation, to ensure that appropriate documentation and reimbursement is received for the level of services rendered to patients. The CDS exercises their judgment and discretion to ensure the clinical information utilized in profiling and reporting outcomes is complete and accurate. An additional goal will be to spend face-to-face time with the providers and quickly help/educate the providers understand their specific documentation trends as illustrated through ICD-10 assignment. On an ongoing basis, the CDS is responsible for supporting the direction and focus of education for providers and the coding staff within their assigned scope of work. The CDS must exercise independent judgment, cranial (critical?) thinking, ability to work independently while interpreting and following CMS guidelines, organizational policies, and procedures.

Providence caregivers are not simply valued – they’re invaluable. Join our team at Swedish Shared Services and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.

• Completes initial medical records reviews of patient records within 24-48 hours of admission for assigned patient population to: (a) independently evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate MS-DRG or APR-DRG assignment critical to compliance with payor billing requirements; and (b) Conducts follow-up reviews of patients every 2-3 days to support and assign a working or final MS-DRG or APR-DRG assignment upon patient discharge as needed.

• Is a positive contributor in how documentation will affect the Hospital Value-Based Purchasing (VBP) results, how patients are included in the Potentially Preventable Readmissions (PPR), and to identify those conditions that may be Hospital Acquired Conditions (HAC), Patient Safety Indicators (PSI), accuracy of Present on Admission (POA) conditions, and penalties will be associated with lack of proper documentation.

• Performs medical record reviews, utilizing independent judgment and discretion to assign a working DRG and obtain appropriate clinical documentation through extensive review of CDI-related documentation areas; draft and submit compliance queries for follow up with providers; conduct follow up reviews of clinical documentation to ensure points of clarification with providers have been accurately recorded in the patients’ medical record

• Collaborates with quality department to improve documentation for quality reporting and report on trends associated with documentation to ensure continued improvement

• Communicates with coders to identify root cause of CDI-Coder final DRG mismatch and resolve incongruence as part of ongoing quality control efforts

• Meets and exceeds established productivity guidelines as well as additional key performance indicators such as review rates, query rates, agreement rates, etc.

• Validates documentation concepts necessary in ICD-10 documentation for the CDI team, clinical teams, and provider.

• Follows queries through to completion.

• Assists in training department staff new to CDI.

• Maintains flexibility in supporting multiple hospitals based on organizational need regardless of system variation.

• Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-10-CM coding. Attends mandatory coding seminars on annual basis (IPPS updates) for inpatient coding. Quarterly review of AHA Coding Clinic. Attends Quarterly Coding Updates and all coding conference calls as well as any required CDI education as assigned.

• Utilizes the enterprise standard CDI tool set and follows standard process and procedures. (we are driving enterprise standard processes and tech- this language is key to holding the standards and driving performance)

• Employs a continuous improvement mindset by identifying and communicating opportunities in the development of new and/or changes to standard processes and tools.

• Able to breakdown raw information and undefined problems into specific workable components that in-turn clearly identifies the issues at hand. Makes logical conclusions utilizing independent judgment and discretion, anticipates obstacles and considers different approaches that are relevant to the decision making process.

• Identifies and acts upon opportunities. Motivates others during times of organizational stress, ambiguity, and change. Creates an environment that encourages prudent risk-taking, sharing of best practices, and alerting groups to alternative approaches.

• Consistently displays awareness and sensitivity to the needs of internal and/or external clients. Proactively ensures these needs are met or exceeded.

• Communicates ideas or positions in a persuasive manner that builds support, agreement, or commitment. Takes actions that directly or indirectly influence others to create buy-in, gain trust, and motivate actions in others or win concessions without damaging relationships.

• Voluntarily takes the first steps to identify and address existing and potential obstacles, issues, and opportunities.

• Innovation: Improves organizational performance though the application of original thinking to existing and emerging methods, processes, products and services. Employs sound judgment in determining how innovations will be deployed to produce return on investment.

• Anticipates, identifies and defines problems. Seeks root causes. Develops and implements practical and timely solutions.

• Sets and accomplishes challenging goals. Defines standards in terms of doing what is appropriate and

• Fosters an environment of collaboration in pursuit of common goals. Inspires, motivates and guides others. Develops leadership skills in others by directing, coaching, mentoring, and reinforcing. Encourages and facilitates cooperation within the organization and with client groups; fosters commitment, team spirit, pride and trust.

• An enterprise-wide understanding of business functions and the corresponding technical strategies, benefits, risks, and costs that impact the business. Examples business functions include: marketing, sales, finance, HR, and engineering.

• Expresses technical and business concepts, ideas, feelings, opinions, and conclusions so that others understand or are persuaded to act. Creates an environment that encourages and values the opinions of others, and promotes sharing of information and ideas.

• Understands financial and accounting principles and is able to apply them to analyze financial results, track budgets, set pricing and rates, and report financials.

• Maintains and applies up-to date knowledge of current clinical documentation practices to ensure the medical record accurately reflects patient care and ensures proper coding including MS-DRG, APR-DRG, ICD-10, CPT and HCPCS codes

• Identifies risks and obstacles to plans. Defines scarcity and conflicts of resource needs, and potential constraints. Investigates risks within various organizational elements, assesses impact, and develops contingency plans to address major risks.

• Understands the broader impact of work efforts across the revenue cycle function, critical business processes, and applications. Conceptualizes impact of changes upon workflow and best practices.

Required Qualifications:

• Associates of Science in Nursing or Associates of Science degree in healthcare or other related field

• Washington Registered Nurse License upon hire

• 5 years Clinical experience in acute care setting or equivalent experience in Health Information Management/Coding

• 1 year understanding of MS-DRG and APR-DRG assignment and fundamentals of establishing a DRG

Preferred Qualifications:

• Bachelor of Science in Nursing or a Bachelor of Science degree in healthcare or other related field (Foreign Medical Graduate)

• 1 year ICD-10 experience and/or understanding

• 3 years Clinical Documentation Specialist experience in acute care setting

Why Join Providence?

Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally and achieving financial security. We take care of you, so you can focus on delivering our mission of improving the health and wellbeing of each patient we serve.

Accepting a new position at another facility that is part of the Providence family of organizations may change your current benefits. Changes in benefits, including paid time-off, happen for various reasons. These reasons can include changes of Legal Employer, FTE, Union, location, time-off plan policies, availability of health and welfare benefit plan offerings, and other various reasons.

About Providence

At Providence, our strength lies in Our Promise of “Know me, care for me, ease my way.” Working at our family of organizations means that regardless of your role, we’ll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

Check out our benefits page for more information about our Benefits and Rewards.

About the Team

Providence Swedish is the largest not-for-profit health care system in the greater Puget Sound area. It is comprised of eight hospital campuses (Ballard, Edmonds, Everett, Centralia, Cherry Hill (Seattle), First Hill (Seattle), Issaquah and Olympia); emergency rooms and specialty centers in Redmond (East King County) and the Mill Creek area in Everett; and Providence Swedish Medical Group, a network of 190 primary care and specialty care locations throughout the Puget Sound. Whether through physician clinics, education, research and innovation or other outreach, we’re dedicated to improving the wellbeing of rural and urban communities by expanding access to quality health care for all.

Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement.

Requsition ID: 262788
Company: Swedish Jobs
Job Category: Documentation Management
Job Function: Quality/Process Improvements
Job Schedule: Full time
Job Shift: Day
Career Track: Nursing
Department: 3900 SS Clincal Doc Integr
Address: WA Seattle 747 Broadway
Work Location: Swedish First Hill 747 Broadway-Seattle
Pay Range: $47.13 - $74.61
The amounts listed are the base pay range; additional compensation may be available for this role, such as shift differentials, standby/on-call, overtime, premiums, extra shift incentives, or bonus opportunities.

Check out our benefits page for more information about our Benefits and Rewards.