Job Description
Clinical Documentation Specialist
Job Title: Clinical Documentation Specialist
Req: 2025-1053
Location: VMC Main Campus
Department: Health Information Management
Shift: Days Monday - Friday
Employment type: Full-time
FTE: 0
Hours: Days Monday - Friday
City State: Renton, WA
Category: Professional
Salary Range: Min $94,894 - Max $142,341/annual DOE
Job Description
The position facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the documentation improvement process is a key role.
Responsibilities
Reviews EMR for completeness and accuracy for severity of illness and quality using the documentation strategies.
Accurate and timely record review.
Recognize opportunities for documentation improvement.
Initiates severity worksheet for inpatients.
Formulate clinically credible documentation clarifications.
Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety.
Effective and appropriate communication with physicians.
Timely follow up on all cases and resolution of those with clinical documentation clarifications.
Communicates with HIM staff and resolves discrepancies.
Accurate input of data for reconciliation of case.
Provide necessary information and education to physicians and staff to facilitate the appropriate documentation goals.
Identify barriers to completion of documentation goals with appropriate interventions.
Review regulations and coding guidelines through seminars, meetings, and materials.
In cooperation with the director of PFS/HIM, present education sessions to physicians and other VMC providers regarding documentation regulations and chart audit findings.
Maintains confidentiality of all patient information.
Support cost containment through process or quality improvement opportunities.
Other duties as assigned to facilitate accurate, timely patient account management.
Qualifications
Current unrestricted WA State Registered Nurse license, required.
Bachelor's degree in Nursing, preferred.
Minimum five years recent clinical experience as an RN in an acute care setting or with Utilization Review experience.
Pass a pre-hire Clinical Exam with a minimum score of 70%.
Effective communication with providers.
Knowledge of hospital clinical practice standards for physicians and other health care providers.
Knowledge of ancillary service departments, quality control and safety standards.
Critical thinking, problem solving and deductive reasoning skills.
Familiarity with health care audit and research design.
Knowledge of Pathophysiology and Disease processes.
Functional knowledge of DRG coding systems.
Experience with Utilization Review and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.
Knowledge of third-party payer review, reimbursement systems, and utilization monitoring requirements for acute care facilities.
Meet productivity guidelines and demonstrate the ability to learn and develop skills to meet goal standards.
Strong organizational, analytical, writing, and interpersonal skills.
Dependable, self-directed, and pleasant.
Basic computer skills (Windows-based software).
Knowledge of regulatory environment and documentation strategies (upon completion of training).
Knowledge of Core Measures and Patient Safety Indicators (upon completion of training).
Seniorities and Employment
Seniority level: Mid-Senior level
Employment type: Full-time
Job function: Health Care Provider
Industries: Hospitals and Health Care
#J-18808-Ljbffr Valley Medical Center
Job Tags
Full time, Monday to Friday, Shift work,