Clinical Documentation Specialist - Scribe

Description

Mountain View Hospital is looking for a Clinical Documentation Specialist-Scribe to join our team!

JOB SUMMARY:      

The Clinical Documentation Specialist- Scribe (CDSS) will be responsible for assisting the provider in creating and maintaining a patient’s medical record, coordinating, collecting, analyzing and reporting data and other quality measures. The CDSS communicates with providers and other medical staff as needed about the patient’s care which would need to be documented within the electronic health record. The CDSS will review and abstract data from medical records and software programs and enter the information into electronic data bases, registries, or other abstraction software as specified for summary analysis and public reporting as required. The individual will demonstrate an attention to detail, accuracy in entry and abstracting information and proficiency in the required data abstraction tools.

BENEFITS:

Taking care for our community starts with taking care of our own team. Mountain View Hospital is proud to offer its employees competitive and comprehensive benefit packages. Benefits include:

• Medical, Dental and Vision Insurance
• Paid Time Off (vacation, holidays and sick days) and Medical Paid Time Off
• Retirement Plans (401K with up to 6% match)
• Earned Quarterly Bonus Program
• Education Reimbursement Program
• Discount for medically necessary procedures performed at Mountain View Hospital and Idaho Falls Community Hospital

Please note benefits are based on eligibility according to full-time, part-time or PRN status classification.

DUTIES AND RESPONSIBILITIES:

1. Scribes information as it occurs and directed by the provider into the medical record
   1. Scribes accompany the physician upon patient interview and examination
   2. Scribes document the correct time of patient care related actives, which may including physician to physician communication, family communication and re-examination of the patient
   3. When the physician concludes the patient’s encounter, the physician will review all documentation completed by the scribe and make any necessary amendments and sign the chart. The physician is ultimately responsible for the documentation of the patient’s medical encounter.
   4. The physician and scribe will make “ chart rounds” to review patient status, delays and other care-related issues.
   5. All orders for patient care must be communicated by the physician and not the scribe.
   6. Scribes will not participate in any patient care and should refer all requests related to the patient care to the responsible physicians or nursing staff; including but not limited to transporting specimens, answering phones, assisting patient, calling physicians, etc.
2. Facilitate timely and accurate flow of communication
3. Clarify unsigned orders and chart notes with the provider
4. Provide concurrent and/ or retrospective review of the documentation to help improve documentation of all conditions, treatments and care plans to ensure the highest quality of care and reporting of the services.
5. Education to clinical staff or other applicable staff members in appropriate documentation criteria.
6. Understanding of how and when to identify principal and secondary diagnoses in order to accurately reflect the patient’s hospital course utilizing ICD-10-CM with appropriate application of coding conventions and guidelines and ensures accuracy of MS-DRG groupings and/or APC assignment
7. Understanding of federal and/or commercial payer clinical and/or medical policies to ensure clinical validation requirements are met for medical conditions
8. Promote Clinical Documentation Improvement  efforts throughout the organization and collaborate with the provider champions and administration to promote initiatives
9. Foster working relationships with other CDI/ Scribe team members, Utilization Review and Case Management, Coding and Auditing/ Compliance team members
10. Help to develop CDI policies and procedures to include updates to query process, education and training, and performance tracking
11. Performs reviews of medical records, summarizes the findings and accurately enters information into databases as specified.
12. Determines and negotiates the validity of the abstracted data and questions controversial information prior to data entry.
13. Pursue continuing education through clinical experience and other knowledge sources to enhance skills and knowledge in the promotion of quality documentation
14. Determines and negotiates the validity of the abstracted data and questions controversial information prior to data entry
15. Tracks and validates data accuracy and timeliness in accordance with established guidelines.
16. Compiles data into reports to analyze trends and patterns to assist in the identification of improvement activities and reports information to the appropriate departments, committees or individuals in relation to established goals.
17. Works with various departments to assist them in being compliant with quality measures and helps train clinicians and other staff on new protocols.
18. Participates in presentations to educate staff on outcomes and new or changing protocols and collaborates with the clinical team to use outcome data in education.
19. Actively participates in problem identification and resolution and coordinates resolution between the appropriate parties.
20. Accurately interprets and follows frequently changing data definitions and guidelines.
21. Takes ownership of projects, researches data and follows through with detailed action plans.
22. Demonstrates an ability to be flexible, organized and function under stressful situations.
23. Provides accurate and timely written and verbal communication of information in a manner that is understood by all.
24. Able to listen, understand, problem-solve, and carry-out duties to ensure the optimal outcome.
25. Adheres to dress code; appearance is neat and clean.
26. Completes annual education requirements.
27. Maintains patient confidentiality at all times.
28. Reports to work, meetings and professional obligations on time.
29. Wears identification while on duty, uses computerized punch time system correctly.
30. Represents the organization in a positive and professional manner.
31. Actively participates in performance and quality improvement activities and complies with all organizational policies regarding ethical business practices.
32. Understands current issues, practices and trends in healthcare
33. Performs other related duties as required and assigned.

ABOUT MOUNTAIN VIEW:

Mountain View Hospital and our 29 affiliate clinics are committed to providing compassionate, cutting edge care to our patients. We serve the entire Snake River Valley – all the way from Pocatello to Rexburg. Our medical capabilities span everything from wound care to urgent care, oncology to neurology, physical therapy to speech therapy, a Level III NICU, robust robotic surgery department and a continuously expanding rural health practice.

Our work environment is mission driven, people-centric and supportive. It is what sets apart and makes people excited to come to work each day. If you are looking for a career where you can make a difference in your community, we invite you to apply.

Qualifications

Education/Certification:  High School Diploma or GED. CPC certification not required, but preferred

Experience:   1-3 years of medical experience.

Equipment/Technology: Proficient computer skills, to include the navigation of several electronic databases. Knowledge of Microsoft Excel and Word.

Language/Communication: Excellent written and verbal communication skills, demonstrated ability to work independently, show initiative, and meet established goals and deadlines.

Mathematical Skills:  Basic understanding of math and concepts to calculate percent of accuracy and deficiencies.

Mental Capabilities:  Can concentrate for long periods of time in order to complete assigned tasks with a better than average attention span in order to listen, read and remember verbal and written instructions.

Interpersonal:  Contributes toward effective, positive working relationships with internal and external colleagues. Demonstrates cooperation, flexibility, reliability, and dependability in all daily work activities, and a willingness to collaborate with others for the good of the organization

Performance:  Can work well under pressure and meet multiple and competing deadlines. Hold oneself to high standards and professionalism