Clinical Documentation Specialist
Sutter Health
full-time
Posted on:
Location Type: Remote
Location: Remote • California, New Jersey, Washington • 🇺🇸 United States
Visit company websiteSalary
💰 $39 - $109 per hour
Job Level
Mid-LevelSenior
About the role
- Conducts concurrent and retrospective reviews of patient medical records to evaluate the accuracy and completeness of clinical documentation, ensuring notes reflect the severity of patient's illness and quality of care
- Interacts thoughtfully and effectively with physicians, patient care team, and ancillary departments to gather and clarify medical record documentation
- Identifies opportunities for improvement to ensure understanding of documentation requirements, optimize reimbursement for the level of service rendered, and enhance the measurement and reporting of outcomes
Requirements
- Graduate of an accredited school of nursing OR Foreign trained physician
- RN-Registered Nurse of California OR Foreign trained physician CCDS or CDIP certification
- 5 years recent relevant experience
- Clinical knowledge of diagnoses, severity of illness, risk of mortality, co-morbidities and complications
- Knowledge of age-specific needs and the elements of disease processes and related procedures
- Knowledge of current coding classification and reimbursement guidelines and regulations
- Critical thinking with the ability to analyze and interpret medical record/clinical documentation and formulate appropriate physician queries
- Ability to define issues, collect data, establish facts and draw valid conclusions
- Demonstrates a proactive approach in identifying and addressing issues and concerns
- Collaboration skills to facilitate open sharing of information and cooperation with various stakeholders to problem solve and achieve desired results/outcome
- Displays a customer service focus in all decisions and actions
- Ability to communicate through verbal and written means, and to present information to a variety of audiences
- Ability to create and translate data into reports and presentations for appropriate audience
- Organization skills to effectively manage and/or re-prioritize activities and projects to meet deadlines while maintaining a high degree of responsiveness
- Ability to interact and maintain effective working relationships with those contacted in the performance of required duties
- Demonstrates respect for cultural and linguistic differences and promotes an inclusive work environment
- Demonstrates initiative in providing feedback/input to improve workflow/processes
- Ability to work effectively in a dynamic and fast-paced environment with changing business priorities
- Ability to maintain and work discreetly with confidential information
- Ability to use essential applications and/or databases associated with the role’s duties and responsibilities.
Benefits
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Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical documentationmedical record reviewcoding classificationreimbursement guidelinesdata analysiscritical thinkingpatient diagnosesseverity of illnessco-morbiditiesdisease processes
Soft skills
collaborationcommunicationcustomer serviceorganizationinitiativeproblem solvingrespect for diversityadaptabilityproactive approachinterpersonal skills
Certifications
RN-Registered Nurse of CaliforniaCCDS certificationCDIP certification