What are the responsibilities and job description for the Clinical Documentation Specialist RN (per diem) position at EvergreenHealth?
Wage Range: $47.70 - $76.31 per hour
Posted wage ranges represent the entire range from minimum to maximum. For jobs with more than one level, the posted range reflects the minimum of the lowest level and the maximum of the highest level. Some positions also offer additional premiums based on shift, certifications or degrees. Job offers are determined based on a candidate's years of relevant experience, level of education and internal equity.
Job Summary:
Working under department management the Clinical Documentation Specialist RN ensures the documentation in the patient health record accurately reflects the severity of illness, expected risk of mortality and the level of services provided to the patient. Utilizing defined review and query processes the CDI RN completes a comprehensive review of inpatient medical records and facilitates clinical documentation correction through collaborative interaction with providers, other patient care givers and with the Medical Center Coding Staff to ensure the encounter record is complete and accurate for reimbursement and outcome reporting.
Primary Duties:
- Reviews inpatient admissions to identify and improve clinical documentation in the medical record to reflect appropriate severity of illness, risk of mortality and quality of care provided. Uses a worksheet format to document reviews in order to facilitate reporting and process improvement activities.
- Communicates with physicians and coders to ensure accurate and complete documentation in the medical record that reflects the clinical condition of the patient in language that can be coded appropriately.
- Utilizes clinical knowledge and understanding of coding guidelines to analyze clinical information and assign a working DRG
- Formulates compliant and credible clinical documentation queries to improve documentation
- Conducts timely post discharge reviews for clinical validation, DRG mismatches or other documentation clarification need.
- Performs other duties as assigned.
License, Certification, Education or Experience:
REQUIRED for the position:
- Current State of Washington RN license
- Bachelors of Science degree in Nursing
- Five (5) years of experience as an RN with a minimum of three year’s acute care or case management experience
- Clinical knowledge with recent acute inpatient clinical experience
- Current American Heart Association Healthcare Provider BLS certification by date of hire
- Training in clinical documentation at time of hire or must obtain within three months of hire.
- Knowledge of the healthcare financial environment, reimbursement and levels of care.
- Training in clinical documentation at time of hire or must obtain within three months
- Oral and written language skills; visual and aural skills in order to communicate
- Accountability for professional nursing practice, commitment to patient care and commitment to uphold the Patient Bill of Rights.
DESIRED for the position:
- Master’s degree in Nursing or other experience and /or educational preparation that would provide the foundation for Nursing Case Management CCDS certification
- CCDS certification
- Recent coding or CDI software
Benefit Information:
Choices that care for you and your family
Choices that care for you and your family
At EvergreenHealth, we appreciate our employees’ commitment and contribution to our success. We are proud to offer the following benefits and resources for our per diem staff to help maintain and improve health and financial well-being.
- Washington Paid Sick Leave (WPSL)
- Participation in 457(b) retirement plan
- Free parking
- Cafeteria & Gift Shop Discount
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Salary : $48 - $76
