The clinical documentation specialist collaborates extensively with physicians, nursing staff, other patient caregivers and coding staff to improve the quality and completeness of documentation of care provided and coded for coordination, abstraction, and submission of accurate data required by CMS. Facilitates concurrent modifications to clinical documentation to insure commensurate reimbursement of clinical severity and services rendered to patients with a DRG based payer (Medicare, Medicaid). Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Communicates with and educates all clinical staff concerning accurate and effective clinical documentation
EDUCATION: RN; Graduate of accredited school of nursing. BSN preferred.
CERTIFICATION/LICENSES: Licensed as a Registered Nurse in the State of New Mexico. BLS certification issued through American Heart Association, required.
Basic computer skills in word processing and spreadsheet utilization.
Excellent written and verbal communication skills.
Proficient in computer use (desktop and/or laptop).
Demonstrates basic knowledge regarding HIM coding standards.
Analytic skills necessary to accurately assess patient medical records.
Excellent interpersonal skills and ability to work on a team in order to influence physician documentation processes.
Ability to be flexible and adjust to workload/assignment changes and interruptions.
EXPERIENCE: Minimum of 5 years recent experience in an acute care setting in a clinical nursing field required. Prior experience in clinical documentation improvement, utilization review/management, discharge planning, quality management, case management or coding preferred.
NATURE OF SUPERVISION:
-Responsible to: Director of Case Management Services
ENVIRONMENT: Bloodborne pathogen: A
General office environment and general hospital department/nursing units.
PHYSICAL REQUIREMENTS: Ability to walk and stand 80% of work time.
Each Associate, regardless of position, is expected to act in keeping with CHRISTUS St. Vincent's (CSV) mission. Associate's performance will be evaluated upon the following:
Core Values - Demonstrates CSV Core Values (Stewardship, Earning Trust, Respect & Teamwork, Value, Inclusive, Community Benefit, Engaged) in relationships and work.
Creativity - Comes up with a lot of new and unique ideas; easily makes connections among previously unrelated notions; tends to be seen as original and value-added in brainstorming settings.
Customer Focus - Is dedicated to meeting the expectations and requirements of internal and external customers; gets first hand customer information and uses it for improvements in products and services; acts with the customers in mind; established and maintains effective relationships with customers and garnishes their trust and respect.
Decision Quality - Makes good decisions (without considering how much time it takes) based upon a mixture of analysis, wisdom, experience, and judgment; most of his/her solutions and suggestions turn out to be correct and accurate when judged over time; sought out by others for advice and solutions.
Drive for Results - Can be counted on to exceed goals successfully; is constantly and consistently one of the top performers; very bottom-line oriented; steadfastly pushes self and others for results.
Peer Relationships - Can quickly find common ground and solve problems for the good of all; can represent his/her own interests and yet be fair to other groups; can solve problems with peers with a minimum of noise; is seen as a team player and is cooperative; easily gains trust and support of peers; encourages collaboration; can be candid with peers.
Priority Setting - Spends his/her time and the time of others on what's important; quickly zeros in on the critical few and puts the trivial many aside; can quickly sense what will help or hinder accomplishing a goal; eliminates roadblocks; creates focus.
Healthstream (HLC) modules completed by assigned date.
Attend 2 of the Town Hall Meetings per fiscal year.
Maintain licensure or certification without lapse, if required for the position.
Maintain BLS/ACLS certification, if required for the position.
Attendance: Follows attendance and tardiness procedures.
Educational Requirements: Completes all annual educational requirements in a timely manner.
Dress Code: Follows dress code and appearance standards; appearance is neat and clean. Wears identification badge, with name and picture showing, while on duty.
Department Meetings: Attends a minimum of 80% of staff meetings annually; reads all meeting minutes.
Safety: Follows necessary and pertinent safety precautions during the performance of job duties, to prevent injury to self and/or others and to prevent damages to hospital equipment/property.
HIPAA: Follows the CHRISTUS Health guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of a patient's Protected Health Information (PHI).
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.