Intermountain Healthcare RN Clinical Document Specialist - Intermountain Medical Center (Full Time) in Salt Lake City, Utah
Greater Salt Lake area
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The Clinical Documentation Specialist (CDS) reviews medical records spanning the continuum of care to facilitate an accurate reflection of the complexity and totality of the patient's health by improving the quality of provider documentation. The efforts of the CDS assist in enhancing the delivery of safe care. The CDS role involves extensive education on pathophysiologic process, HIM and coding rules and regulations. The CDS workflow includes record review and interaction with physicians, HIM professionals and nursing staff. Active participation in team meetings and education of staff in Clinical Documentation Integrity (CDI) processes are key roles of the CDS nurse.
Essential Job Duties
- Educates all members of the patient care team, including medical staff, on documentation guidelines on an ongoing basis. Assists with orientation of new hires as needed.
- Reviews inpatient medical records for identified payer populations.
- Analyzes clinical status of patient, current treatment plan, and past medical history.
- Performs chart reviews to identify potential gaps in physician documentation.
- Review rates meet productivity standards within 6 months of hire.
- Formulates physicians' clarifications to ensure that clinical documentation reflects the severity of illness and level of service rendered to patient.
- Ensures current, accurate, and complete documentation of medical record.
- Clarifies clinical documentation through extensive interaction with physicians, nursing staff and other patient caregivers following Intermountain's Provider Documentation Query Policy.
- Facilitates and plans monthly Task Force meetings for quality control of accuracy, completeness and timeliness of documentation; analyzes, interprets and reports findings of program impact to management.
- Acts as a resource and consultant to staff and physicians regarding clinical documentation.
- Benefits Eligible: Yes; Medical, Dental, Vision, Education Assistance. Click here for more details
- Shift Details: Full time exempt, 40 hours per week
- Department: Clinical Documentation Integrity - Intermountain Medical Center
- RN license in state of practice.
- Bachelor's degree in Nursing (BSN) from an accredited institutionor Associate's degree in Nursing from an accredited institution with at least one coding credential from AHIMA or AAPC. Degree will be verified.
- 2 years of clinical experience.
- Experience with pathophysiology and disease processes.
- Basic computer skills.
- Ongoing need for employee to see and read information, labels, monitors, identify equipment and supplies, and be able to assess patient needs.
- Frequent interactions with patient care providers, patients, and visitors that require employee to verbally communicate as well as hear and understand spoken information, alarms, needs, and issues quickly and accurately, particularly during emergency situations.
- Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use and typing for documenting patient care, accessing needed information, etc.
- Clinical experience in ICU, CCU, or intermediate care.
- Experience with Clinical Documentation Integrity.
All positions subject to close without notice. Intermountain Healthcare prohibits discrimination on the basis of race, ethnicity, religion, color, national origin, sex, age, sexual orientation, gender identity/expression, veteran status, disability and/or genetic information.
Working Hours 40
Primary Work Location Intermountain Medical Center
Job Type Full Time
Location US-UT-Salt Lake City