Clinical Documentation Specialist - Inpatient Rn

At Scripps Health, you will experience the pride, support, and respect of an organization that has been repeatedly recognized as one of the nation's Top 100 Places to Work.

You'll be surrounded by people committed to making a difference in the lives of their patients and their teammates. So if you're open to change, go ahead and unlock your potential.

The primary goal at Scripps Health is to deliver the very best patient experience.

In this role, you will have the opportunity to join Scripps Centralized Clinical Documentation team.  You will provide concurrent review of the Clinical Documentation in the inpatient medical record to assist in properly reflecting the patient acuity; review the medical record with a clinical lens to identify any missing or understated diagnoses.

As a Clinical Documentation Specialist, you will:

• Review inpatient records for our five Scripps Health hospitals.
• Facilitate improvement in medical record documentation by interacting with and educating physicians, nurses and coding staff to ensure medical records accurately reflect patient acuity for quality reporting and insurance reimbursement. 
• Understand the importance that this Clinical Documentation work has and how it has the prospect to make a large impact enterprise-wide and support a high-quality patient experience.
• Complete admission reviews and work closely with coding staff to ensure accuracy in code assignments that reflect the patient's clinical status and care.
• Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record. Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge.
• Maintain accurate records of review activities, ensuring reports and outcomes of Clinical Documentation improvement (CDI) efforts are valid.
• Provide education to the healthcare team on an ongoing basis regarding documentation opportunities, coding, and reimbursement issues, and relevant quality and performance improvement activities.
• Provide a concurrent review of the Clinical Documentation in the inpatient medical record to assist in properly reflecting the patient acuity; review the medical record with a clinical lens to identify any missing or understated diagnoses

This is a Full-Time (80 hours every two weeks) benefited and salaried position working day shifts on Monday - Friday. This is a remote position and the candidate must be local in San Diego.

Required Education/Experience/Specialized Skills:

• CA RN License or MD required.
• Experienced in using electronic medical records and computer applications.
• Excellent communication and critical thinking skills.
• Strong leadership qualities including the ability to motivate, teach and facilitate individuals and groups on reaching objectives of program.
• Ability to review and interpret clinical information and knowledge of hospital regulatory requirements desired.
• Computer literacy and ability to efficiently and effectively obtain clinical information from a variety of sources necessary.

Preferred Education/Experience/Specialized Skills/Certification:

• Bachelors preferred.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)
• Registered Health Information Administrator (RHIA)
• Professional work experience as an inpatient Clinical Documentation Specialist.