Clinical Documentation Specialist- Care Management (Per Diem)
The Clinical Documentation Specialist in Care Management specializes in ensuring that the documentation in the patient health record reflects the clinical acuity of the patient. Works in partnership with physicians to ensure clinical information in medical record is present and accurate; and with the Medical Center Coding Staff to support that appropriate clinical severity is captured for the level of service rendered to all patients within a DRG-based payor system and also are proficient in the RN case manager role.
Reviews inpatient admissions to identify and improve clinical documentation in the medical record to reflect appropriate severity of illness, risk of mortality and quality of care provided. Uses a worksheet format to document reviews in order to facilitate reporting and process improvement activities.
Communicates with physicians and coders to ensure accurate and complete documentation in the medical record that reflects the clinical condition of the patient in language that can be coded appropriately.
Comprehensively screens and assesses patients, using predetermined criteria, through the collection and documentation of data. Uses screening and case finding to identify appropriate patients for care management. Interprets assessment data to identify patient and/or families at high risk.
Develops, implements, monitors, and modifies a personalized plan of care in collaboration with the patient, family and all members of the health care team based on agreed upon patient outcomes and goals.
Performs other duties as assigned.
License, Certification, Education or Experience:
REQUIRED for the position:
-Current State of Washington RN license
-Bachelors of Science degree in Nursing
-Five (5) years of experience as an RN with a minimum of three year’s acute care or case management experience
-Current American Heart Association Healthcare Provider BLS certification by date of hire
-Training in clinical documentation at time of hire or must obtain within three months of hire.
-Ability to assess, plan, implement and evaluate patient care.
-Knowledge of the healthcare financial environment, reimbursement and levels of care.
-Knowledge of community resources and how to access them effectively and efficiently.
-Interpersonal skills necessary to lead and coordinate an interdisciplinary team and deal effectively with patients and families from a variety of backgrounds and with varied emotional and medical needs.
-Age-appropriate developmental assessment skills.
-Excellent verbal and written skills to communicate, ensure and deliver safe patient care and to provide a legal record of this care.
-Accountability for professional nursing practice, commitment to patient care and commitment to uphold the Patient Bill of Rights.
DESIRED for the position:
-Master’s degree in Nursing or other experience and /or educational preparation that would provide the foundation for Nursing Case Management CCDS certification