Cottage Health · 1 day ago
Clinical Documentation Specialist
Santa Barbara, CA
Full-time
Onsite
Mid Level
$54/hr - $83/hrCottage Health is a leading acute care hospital system located on the central coast of California, known for its superior patient care and innovation. They are seeking a Clinical Documentation Specialist to ensure that physician documentation supports the severity of patient illness and risk of mortality through concurrent reviews of clinical documentation.
HealthcareWellnessHealth CareMedical
Responsibilities
Provides concurrent and subsequent reviews of the clinical documentation in the medical record using documentation improvement guidelines
Evaluates and identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure overall quality and completeness of the record
The key responsibility is to review the chart for information not currently in the chart but supported by clinical indicators; then queries the medical staff when necessary through written or verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality
Performs a thorough chart review to determine the most appropriate principal diagnosis of the patient
Performs a thorough chart review to identify co-morbidities/complications and documents these appropriately within the concurrent CDS worksheet
Demonstrates an understanding of the importance of, and makes an effort to capture, all appropriate secondary diagnoses
Coordinates with coding/HIM/UR and other departments to ensure the coded record reflects the acuity of patients and level of provider care
Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization
Maintains the ability to be flexible and prioritizes daily responsibilities
Uses strong and professional communication skills with providers to clarify information in the medical record
Uses appropriate and compliant querying tools (templates) to capture needed documentation
Conducts follow-up on unanswered queries during the patient stay to obtain a response to unanswered queries
Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or individually with physicians
Reviews the progress of the CDI program by interpreting performance, process, and quality ratings reports
Identifies areas of focus through report analysis
Qualification
Required
Associate's Degree Nursing
Basic MS office skills; including Excel, Word, Outlook. Basic proficiency in computer applications
Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators. Up-to-date clinical knowledge
Ability to create and maintain strong relationships and confidently discuss clinical diagnoses. Skills in negotiation, conflict resolution, follow through and follow up. Ability to work independently in a time-oriented environment
The employee communicates effectively. Excellent and professional written and verbal communication skills. Ability to write concisely and effectively when communicating with providers
Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization. Good organizational skills with attention to detail and accuracy. Maintains the ability to be flexible and prioritizes daily responsibilities
Preferred
Bachelor's Degree or higher in Nursing
Current RN License
EPIC, 3M 360, 3M eMD
Company
Cottage Health
Mission Statement: To provide superior health care for and improve the health of our communities through a commitment to our core values of excellence, integrity, and compassion.
Founded in 1966
1001-5000 employees
Funding
Current Stage
Late StageTotal Funding
$0.2MKey Investors
Hearst Foundations
2022-01-19Grant· $0.2M
Leadership Team
Richard Beswick
Vice President for Research and Chief Research Officer
Sheri R.
Vice President, Information Technology & Chief Information Officer
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