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Clinical Documentation Specialist

SCL Health System Grand Junction, CO
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Job Description

Clinical Documentation Specialist-18000617 

SCL Health is excited to be expanding their CDI team and are looking for additional Clinical Documentation Specialists to join their collaborative and well-supported teams in Denver, Billings and Grand Junction. This opportunity will offer strong career growth possibilities, as well as consideration for possible remote opportunities (experienced CDS candidates only) for those living outside the SCL Health market.

 

The Clinical Documentation Specialists will work in a 100% electronic system with EPIC and 3M 360 CDIS, working directly with physicians as well as other care team members. This team is supported by two educators, allowing for the support you need to be successful in your day-to-day role.

 

This advanced CDI team is progressive and on the forefront of industry CDI strategies in alignment with national organizations such as ACDIS and AHIMA. 

 

Duties/Responsibilities

  • The Clinical Documentation Specialist ensures clinical documentation is accurate, compliant and specific to reflect the severity of illness and risk of mortality of the patient.
  • Facilitates concurrent documentation of the medical record to realize accurate and complete representation of the Severity of Illness and Risk of Mortality of the patient, resulting in the appropriate ICD-10 code/DRG assignment.
  • Works collaboratively with medical, nursing, ancillary, and coding staff to improve the quality of chart documentation.
  • Responsible for identifying complications and co-morbid conditions, specifying co-existing conditions and causal agents, and following-up with physicians responsible for care of the patient for appropriate documentation.
  • Identifies the need to clarify documentation in the medical record and communicates with physicians face-to-face or using the appropriate œquery tools.
  • Stays abreast of coding guidelines, reimbursement methodologies, regulatory compliance and quality based programs. Maintains thorough and current knowledge of clinical care and treatment options to critically assess appropriateness of documentation. Thorough clinical knowledge of disease processes, pathophysiology and pharmacology is required.
  • Serves as a resource and educates physicians on linking coding guidelines and medical terminology to capture accurate final code assignment.
  • Promotes mission, vision, and values of SCL Health, and abides by service behavior standards.
  • To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. 
  • Understands and is able to articulate concepts to physicians and other health care professionals in an effort to educate on clinical documentation requirements.
 

Required:

  • Bachelor's level degree in Nursing required.
  • Active RN license in good standing required.
  • Three (3) years of nursing experience in an acute care setting within the last 10 years or 1 or more year experience as a Clinical Documentation Specialist in an acute care setting within the past 2 years required.

Preferred:

  • CDIP or CCDS certification preferred.
  • CDI experience preferred.
  • 3M CDIS and Epic preferred or ability to learn.
 

Organization

: St. Marys Medical Center, Grand Junction, CO

Primary Location

: CO-Grand Junction
Department: SYS-Clinical Doc Improvement

Schedule

: Full-time

Shift

: Day Shift

Job Posting

: Feb 8, 2018, 12:16:26 PM
FTE: 1.0

 Medical Records, HIM, Coding

Recruiter

: Nicole Moyse

Job Details

Date Posted May 13, 2018
Date Closes June 12, 2018
Requisition 18000617
Located In Grand junction, CO
SOC Category 00-0000.00
Location