Clinical Documentation Specialist - RN (Remote in OR)
Company: Samaritan Health Services
Location: Corvallis
Posted on: June 21, 2022
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Job Description:
This position is a remote position within the state of
Oregon.JOB SUMMARY/PURPOSEProvides analysis, information and
education to assist physicians and/or staff in using terminology
that improves and supports documentation of patient care. Performs
concurrent review and analysis of the clinical facts documented in
the medical records. Concurrently queries the medical staff and
other members of the healthcare team to obtain accurate and
complete chart documentation that appropriately supports the
severity of the patient's illness. Plans and provides education to
the healthcare team regarding documentation requirements, clarity
and completeness.DEPARTMENT DESCRIPTIONThe Clinical Documentation
Improvement Department is the fundamental, strategic part of
Samaritan Health Services' efforts to improve patient outcomes,
enhance clinical documentation guidelines, ensure compliance and
upgrade financial performance. The CDI program is a comprehensive,
multi-disciplinary, hospital wide initiative promoting accurate,
clear, concise, complete, and compliant documentation efforts. CDI
professionals analyze data, formulate concurrent & retrospective
physician queries, track CDI performance metrics, and successfully
collaborate with other healthcare professionals. CDI professionals
engage in a beneficial collaborative partnership with the
Healthcare team to secure accurate clinical documentation in the
medical record using compliant methodologies, which will result in
appropriate code assignment, correct reimbursement, decreased
claims denials & reduced RAC
reviews.EXPERIENCE/EDUCATION/QUALIFICATIONSOne (1) of the following
required:Current unencumbered Oregon Registered Nurse license and
five (5) years nursing experience in an inpatient acute care
setting. BSN and experience in ICU-CCU preferred.High school
diploma or equivalent, RHIT with CCS, and six (6) years inpatient
coding experience. Experience in the following required:Clinical
Documentation. Inpatient Coding and Reimbursement. Quality
assurance chart review, coding, auditing and /or case management.
Acute care utilization review or discharge planning. Experience or
training in Excel, Word and EMR required. Certified Clinical
Documenation Specialist (CDIS) preferred.
KNOWLEDGE/SKILLS/ABILITIESKnowledge of clinical documentation
requirements, DRG assignment, clinical conditions/procedures,
quality outcome standards and documentation requirements to meet
those standards.Communication: Effective written and verbal
communication skills to perform group presentations, tactfully
discuss issues, and listen to and understand complex
information/situations. Ability to work with all levels within the
organization, facilitate communication, and effectively document
related activities.Computer Literacy: Proficiency in computer
applications, including word processing, spreadsheets, databases,
and information systems.Confidentiality: Knowledge of State and
Federal (HIPAA) laws pertaining to confidentiality of protected
health information. Ability to comply with laws and maintain
confidentiality of patient information.Time Management: Ability to
organize, plan and prioritize work to complete within required time
frames and to follow-up on pending issues. Ability to perform
multiple tasks simultaneously and thrive in dynamic fast-paced
environments and under pressure.PHYSICAL DEMANDSRarely(1 - 10% of
the time)Occasionally(11 - 33% of the time)Frequently(34 - 66% of
the time)Continually(67 - 100% of the time)CLIMB - STAIRS LIFT
(Floor to Waist: 0"-36") 40 - 60 LbsLIFT (Floor to Waist: 0"-36")
60 or more LbsSQUAT Static (hold > 30 sec)KNEEL (on knees)SIT
LIFT (Floor to Waist: 0"-36") 20 - 40 LbsCARRY 2-handed, 20 - 40
poundsSQUAT RepetitiveROTATE TRUNK SittingREACH - UpwardPUSH (20-40
pounds force) PULL (20-40 pounds force) STAND WALK - LEVEL
SURFACELIFT (Floor to Waist: 0"-36") 0 - 20 LbsLIFT (Knee to chest:
24"-54") 0 - 20 LbsLIFT (Waist to Eye: up to 54") 0 - 20 LbsLIFT
(Overhead: 54" and above) 0 - 20 LbsCARRY 1-handed, 0 - 20
poundsCARRY 2-handed, 0 - 20 poundsBEND FORWARD at waistROTATE
TRUNK StandingREACH - ForwardMANUAL DEXTERITY Hands/wristsFINGER
DEXTERITYPINCH FingersGRASP Hand/Fist PUSH (0-20 pounds force) PULL
(0-20 pounds force)None specified
Keywords: Samaritan Health Services, Corvallis , Clinical Documentation Specialist - RN (Remote in OR), Healthcare , Corvallis, Oregon
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