Job Information
Valley Medical Center Clinical Documentation Specialist (RN Nurse) in Renton, Washington
WE are Valley. Shouldn't You Be, Too?
At Valley, we serve a critical role in helping maintain and improve the health of our community. We share common core values such as compassion, respect, trust and teamwork. And we have an honest passion for helping others, patients and staff alike. If this excites and motivates you, consider joining our team!
Become Part of Our Valley Family
When you join Valley, you join a remarkable and motivated team dedicated to caring for our community and each other. From the operating room to the board room and all of the departments and clinics in between, we are committed, capable and eager to share our expertise and passion for helping others.
The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.
JOB OVERVIEW: The Clinical Documentation Specialist position facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the documentation improvement process is a key role.
DEPARTMENT: Health Information Management
HOURS OF WORK: Days Monday - Friday.
RESPONSIBLE TO: Manager, Clinical Documentation Improvement
PREREQUISITES:
- Current unrestricted WA State Registered Nurse license, required.
- Bachelor's degree in nursing, preferred.
- Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review
- Pass a pre-hire Clinical Exam with a minimum score of 70%
- Effective communication with Providers
QUALIFICATIONS:
- Knowledge of hospital clinical practice standards for physicians and other health care providers.
- Knowledge of ancillary service departments, quality control and safety standards.
- Critical thinking, problem solving and deductive reasoning skills.
- Familiarity with health care audit and research design.
- Knowledge of Pathophysiology and Disease process.
- Functional knowledge of DRG coding systems.
- Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.
- Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.
- Meet productivity guidelines.
- Ability to learn/develop the skills necessary to perform and meet goal standards
- Organizational, analytical, writing, and interpersonal skills
- Dependable, self-directed, and pleasant
- Critical thinking, problem solving and deductive reasoning skills
- Knowledge of Pathophysiology and Disease Process
- Basic Computer skills - familiarity with Windows based software programs
- Knowledge of regulatory environment
- Understand and support documentation strategies (upon completion of training)
- Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)
PERFORMANCE RESPONSIBILITIES:
A. Generic Job Functions: See Generic Job Description for Administrative Partner.
B. Essential Responsibilities and Competencies
Reviews EMR for completeness and accuracy for severity of illness and quality using the documentation strategies.
Accurate and timely record review.
Recognize opportunities for documentation improvement.