This position is located at St. Marys Hospital in Grand Junction, CO
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
- 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 query 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.