Love what you do; Love where you live
The Clinical Documentation Improvement Specialist facilitates improvement in the quality and completeness of patient records on a concurrent basis, using a multi-disciplinary process. The CDIS applies clinical knowledge and coding knowledge to evaluate clinical indicators, diagnoses, and treatment plan for assigned inpatients, to identify gaps in physician documentation.
Required Behaviors:
• As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization: Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.
Required Qualifications:
Preferred Qualifications:
Duties and Responsibilities:
Safety, Courtesy, Effectiveness, and Stewardship
Physical Demands and Environmental Work Conditions:
• Prolonged standing/sitting/walking
• Fast paced environment
• High level of activity with many interruptions
• Possible exposure to communicable disease
• Repetitive motions (i.e.; keyboard usage)
Sensory Requirements:
The employee will need to be able to hear:
• Alarms on equipment/fire alarms/overhead announcements
• Patients/family/physician verbal discussion
• Feedback from other healthcare providers
The employee will need to be able to see:
• Focus on close-up and distant objects
• Have intact: peripheral vision and depth perception
The Clinical Documentation Improvement Specialist facilitates improvement in the quality and completeness of patient records on a concurrent basis, using a multi-disciplinary process. The CDIS applies clinical knowledge and coding knowledge to evaluate clinical indicators, diagnoses, and treatment plan for assigned inpatients, to identify gaps in physician documentation.
Required Behaviors:
• As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization: Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.
Required Qualifications:
- Registered Nurse
- Minimum of 3 years strong clinical background in acute care
- Current NM Licensure
- Excellent written and verbal communication skills
- Analytical thinking skills
- Team-oriented
- Basic computer skills
- Highly-organized
Preferred Qualifications:
- BSN Certified
- Clinical Documentation Specialist (CCDS)
- Coding experience
Duties and Responsibilities:
- Comprehensively reviews patient records, concurrently and retrospectively, to assure a complete and accurate representation of the severity of illness and use of resources.
- Assigns Working DRG
- Works closely with physicians, Case Management staff, and Coding to review documentation coding practices analyzing whether documentation supports the acuity of the patients.
- Identifies gaps in physician documentation and facilitates appropriate Documentation Improvement interventions with physicians.
- Identifies Clinical Documentation Improvement (CDI) best practices, benchmarks and improvement strategies to augment compliance objectives.
- Stays current on information pertaining to coding, compliance, clinical guidelines and payer requirements as it relates to MSDRG assignment, documentation and other payment requirements.
- Each employee is responsible for implementing SJRMC's Service Standards into their daily work:
Safety, Courtesy, Effectiveness, and Stewardship
- Perform related duties as required.
Physical Demands and Environmental Work Conditions:
• Prolonged standing/sitting/walking
• Fast paced environment
• High level of activity with many interruptions
• Possible exposure to communicable disease
• Repetitive motions (i.e.; keyboard usage)
Sensory Requirements:
The employee will need to be able to hear:
• Alarms on equipment/fire alarms/overhead announcements
• Patients/family/physician verbal discussion
• Feedback from other healthcare providers
The employee will need to be able to see:
• Focus on close-up and distant objects
• Have intact: peripheral vision and depth perception