Clinical Documentation Specialist RN (1.0 FTE, Days)

Wage Range: $48.66 - $77.84 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
Knowledge of the healthcare financial environment, reimbursement and levels of care.
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 experience in CDI and/or Coding strongly preferred

Benefit Information:
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 a suite of quality benefits and resources that are comprehensive, flexible, and competitive to help our staff and their loved ones maintain and improve health and financial well-being.

Medical, vision and dental insurance
On-demand virtual health care
Health Savings Account
Flexible Spending Account
Life and disability insurance
Retirement plans 457(b) and 401(a) with employer contribution)
Tuition assistance for undergraduate and graduate degrees
Federal Public Service Loan Forgiveness program
Paid Time Off/Vacation
Extended Illness Bank/Sick Leave
Paid holidays
Voluntary hospital indemnity insurance
Voluntary identity theft protection
Voluntary legal insurance
Pay in lieu of benefits premium program
Free parking
Commuter benefits
Cafeteria & Gift Shop Discount

View a summary of our total rewards available to you as an EvergreenHealth team member by clicking on the link below.

EvergreenHealth Benefits Guide

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