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Clinical Documentation Integrity (4000-81605)

Full Time

$79,144 - $98,946 annually

25796

Full Time salaried position

RN- Clinical Documentation Specialist Position Overview

The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through review of medical record and collaborative interactions with Physicians, HIM Coders, Case Managers and other healthcare team members.

 

As an RN Clinical Documentation Specialist at Asante, you will have the opportunity to:

·        Promote appropriate clinical documentation at the point-of-care to accurately reflect the patient's severity of illness, working diagnosis, and clinical course of hospitalization.

·        Educate members of the healthcare team on documentation guidelines

·        Work collaboratively with Physicians, HIM Coders, Case Managers and other healthcare team members.

 

This is not a remote position and will be primarily

located at Asante Three Rivers Medical Center in Grants Pass.

Education

·        Bachelor of Science or higher in Nursing or other related area, preferred

Experience

·        3-5 years broad-based clinical nursing experience in an acute hospital setting is required. 

·        Experience in multiple clinical practice areas such as Critical Care, Labor & Delivery, Emergency Dept, Surgical Services, and/or physician clinics, preferred

·        Experience in the healthcare revenue cycle, denials management, auditing, or case management, preferred

·        Experience in a hospital or physician practice billing office.  

·        Demonstrates strong organizational and communication skills with demonstrated leadership ability, required

·        Adaptable communication skills to a wide variety of encounters with the healthcare team, required

·        Highly developed problem solving skills and self- directed, motivated behavior, required

·        Ability to develop and maintain supportive, collaborative relationships with Physicians, required

·         Demonstrated ability to analyze problems and issues and understand the regulatory and reimbursement impact of those decisions, required

·        Excellent written and verbal communication skills, including the ability to present ideas and concepts effectively to physicians, employees and leadership, required

·        Computer literacy and ability to work in multiple computer programs including word processing, spreadsheets and databases, required   

·        Knowledge of DRG methodology, including ICD diagnosis & procedure coding, PDX selection and coding hierarchy, preferred

·        Ability to identify opportunities for improvement in CDIS processes and to implement changes in process, preferred

·       Ability to manage change process for clinical documentation improvement  with clinical manager, coding, and physicians, preferred

·       Knowledge related to how documentation & coding can impact hospital reimbursement, quality outcomes data, and severity/mortality scores, preferred

·        Knowledge of CMS and other regulatory guidelines, preferred

·        Knowledge related to nursing and healthcare informatics, preferred

·        Experience with EHR's, computer analytics, and database management systems, preferred

License/Certifications 

·        Registered Nurse (RN) licensed by Oregon State Board of Nursing (OSBN) required. 

·        Must obtain Certified Clinical Documentation Specialist (CCDS) through Association for Clinical documentation Improvement Specialists (ACDIS) within 3 years of hire into position.   

·        CCA, CCS, RHIA, RHIT, CDIP – all through AHIMA, preferred   

About Asante and Southern Oregon

Asante is one of the top 15 health systems in the nation and the largest healthcare provider in nine counties.  We are locally owned and based in beautiful Southern Oregon. We provide comprehensive medical care to more than 580,000 people throughout southern Oregon and northern California. Our facilities employ over 5000 people and include Asante Ashland Community Hospital in Ashland, Asante Rogue Regional Medical Center in Medford, Asante Three Rivers Medical Center in Grants Pass, Asante Physician Partners, and additional healthcare partnerships throughout the region. 

 

At Asante we believe that we are defined by our values – the traits that guide us as we serve patients and the community:

 

Excellence - Respect - Honesty - Service – Teamwork

 

Asante is an equal opportunity employer.  We are committed to employ and advance in employment women, minorities, qualified individuals with disabilities and protected veterans.