Clinical Documentation Specialist (RN)

Saint Francis Health System • Full-time • Muskogee, Oklahoma 74401, United States • 1m ago

Current Saint Francis Employees - Please click HERE to login and apply.

Full Time

Job Summary: The Clinical Documentation Specialist facilitates accurate documentation for severity of illness and quality in the medical record. Key functions include extensive record review and direct interaction with medical, nursing, and ancillary staff to capture clinical documentation at the point of care; and health information staff to assure appropriate use of available clinical documentation to reflect accurate diagnosis, co-morbidities, and care provided for the patient. It requires independent decision making of a complex nature based on training in the clinical documentation process. Active participation in team meetings and staff education on the clinical documentation improvement process is a key role.

Minimum Education: Has completed the basic professional curricula of a school of nursing as approved and verified by a state board of nursing, and holds or is entitled to hold a diploma or degree therefrom.

Licensure, Registration and/or Certification: Valid multi-state or State of Oklahoma Registered Nurse License.

Work Experience: Minimum of 5 years of adult acute care experience in med/surg, critical care, emergency room, or PACU.

Knowledge, Skills and Abilities: Organizational, analytical and writing skills. Ability to demonstrate critical thinking, problem solving and deductive reasoning skills. Excellent interpersonal skills and ability to develop relationships. Excellent time management. Knowledge of regulatory guidelines including but not limited to Medicare Part A. Knowledge of Pathophysiology and Disease Process and ability to pass a written clinical competency exam and processes. Basic computer skills.

Essential Functions and Responsibilities: Accurate and timely review and analysis of new admissions for overall quality and completeness of clinical documentation to ensure it accurately reflects the level of service rendered and the severity of patients' illnesses. Systematic review of targeted medical records or select diagnoses as deemed necessary to identify and convey documentation deficiencies. Conduct timely follow up on reviewed cases to assure resolution of all clinical documentation clarifications identified. Recognize opportunities for documentation improvement, formulate clinically credible documentation clarifications, and facilitate correction of documentation deficiencies through extensive interaction with physicians, nurses and ancillary staff. Affective and appropriate communication of documentation improvement observations with attending physicians, nurse practitioner, and physician assistants, nurses, and ancillary staff. Develop and implement plans for education of physician, nursing and ancillary staff on documentation improvements. Works collaboratively with HIM coding specialists to ensure documentation of discharge diagnosis, comorbidities, or complications are a complete reflection of the patient's clinical status and care. Facilitates timely resolution of documentation discrepancies identified on final review. Accurate input of required data elements to facilitate program performance monitoring. Analysis and use data to identify and implement strategies for sustained work process changes that facilitate the documentation management process. Actively participate in team meetings and staff educations on the documentation management program. Act as a resource person to promote collaboration and coordination of patient care, considering age-specific, developmental, cultural, and spiritual needs of the patient.

Decision Making: The carrying out of non-routine procedures under constantly changing conditions, in conformance with general instructions from supervisor.

Working Relationship: Coordinates activities of others (does not supervise). Leads others in same work performed (does not supervise). Works directly with patients and/or customers . Works with internal customers via telephone or face to face interaction. Works with other healthcare professionals and staff. Works frequently with individuals at Director level or above.

Special Job Dimensions: None.

Supplemental Information: This document generally describes the essential functions of the job and the physical demands required to perform the job. This compilation of essential functions and physical demands is not all inclusive nor does it prohibit the assignment of additional duties.

Clinical Document Integrity - Muskogee Campus

Location:

Muskogee, Oklahoma 74401

EOE Protected Veterans/Disability

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