Clinical Documentation Specialist – Level 3
St. Charles Health System
full-time
Posted on:
Location Type: Remote
Location: Arizona • Florida • United States
Visit company websiteExplore more
Salary
💰 $98,488 - $147,742 per year
About the role
- Provides clinical based review and analysis of the documentation in the patient’s medical record
- Supports accurate capture of patient’s complexity and severity of illness
- Utilizes queries of medical staff and other caregivers to clarify and support completeness of documentation
- Collaborates with physician, mid-level providers, and medical records coders to identify principal and secondary diagnoses
- Conducts initial and ongoing concurrent and some retrospective reviews for system wide admissions
- Initiates tracking process and documents findings on EHR tracking system
- Communicates with providers to capture accurate documentation of patient’s severity of illness
Requirements
- Minimum of five (5) years recent CDIS experience
- Proficient use of EPIC and 3M 360 Encompass software programs
- Current Oregon RN License
- CCDS (Certified Clinical Documentation Specialist) or CDIP (Certified Documentation Improvement Practitioner)
- As required by licensure for RN.
Benefits
- Competitive Salary
- Comprehensive benefits including Medical, Dental, Vision for you and your immediate family
- 403b with up to 6% match on Retirement Contributions
- Generous Earned Time Off
- Growth Opportunities within Healthcare
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical documentation reviewmedical record analysisdocumentation completenessdiagnosis identificationconcurrent reviewretrospective reviewEHR trackingdocumentation accuracy
Soft Skills
collaborationcommunication
Certifications
Oregon RN LicenseCCDSCDIP