Clinical Documentation Specialist
RN- Clinical Documentation Specialist Position Overview
The Clinical Documentation Specialist facilitates improvement in the overall quality, completeness and accuracy of medical record documentation through review of medical record and collaborative interactions with Physicians, HIM Coders, Case Managers and other healthcare team members.
This position will require working from all three Asante hospitals (in Medford, Grants Pass, and Ashland). May also include working in the Ambulatory physician offices in Jackson and Josephine counties.
As an RN Clinical Documentation Specialist at Asante, you will have the opportunity to:
Promote appropriate clinical documentation at the point-of-care to accurately reflect the patient's severity of illness, working diagnosis, and clinical course of hospitalization.
Educate members of the healthcare team on documentation guidelines
Work collaboratively with Physicians, HIM Coders, Case Managers and other healthcare team members.
This is not a remote position and will be primarily located at an Asante facility.
Bachelor of Science or higher in Nursing or other related area, preferred
3-5 years broad-based clinical nursing experience in an acute hospital setting is required.
Experience in multiple clinical practice areas such as Critical Care, Labor & Delivery, Emergency Dept, Surgical Services, and/or physician clinics, preferred
Experience in the healthcare revenue cycle, denials management, auditing, or case management, preferred
Experience in a hospital or physician practice billing office.
Demonstrates strong organizational and communication skills with demonstrated leadership ability, required
Adaptable communication skills to a wide variety of encounters with the healthcare team, required
Highly developed problem solving skills and self- directed, motivated behavior, required
Ability to develop and maintain supportive, collaborative relationships with Physicians, required
Demonstrated ability to analyze problems and issues and understand the regulatory and reimbursement impact of those decisions, required
Excellent written and verbal communication skills, including the ability to present ideas and concepts effectively to physicians, employees and leadership, required
Computer literacy and ability to work in multiple computer programs including word processing, spreadsheets and databases, required
Knowledge of DRG methodology, including ICD diagnosis & procedure coding, PDX selection and coding hierarchy, preferred
Ability to identify opportunities for improvement in CDIS processes and to implement changes in process, preferred
Ability to manage change process for clinical documentation improvement with clinical manager, coding, and physicians, preferred
Knowledge related to how documentation & coding can impact hospital reimbursement, quality outcomes data, and severity/mortality scores, preferred
Knowledge of CMS and other regulatory guidelines, preferred
Knowledge related to nursing and healthcare informatics, preferred
Experience with EHR's, computer analytics, and database management systems, preferred
Registered Nurse (RN) licensed by Oregon State Board of Nursing (OSBN) required.
Must obtain Certified Clinical Documentation Specialist (CCDS) through Association for Clinical documentation Improvement Specialists (ACDIS) within 3 years of hire into position.
CCA, CCS, RHIA, RHIT, CDIP all through AHIMA, preferred
About Asante and Southern Oregon
Asante is one of the top 15 health systems in the nation and the largest healthcare provider in nine counties. We are locally owned and based in beautiful Southern Oregon. We provide comprehensive medical care to more than 580,000 people throughout southern Oregon and northern California. Our facilities employ over 5000 people and include Asante Ashland Community Hospital in Ashland, Asante Rogue Regional Medical Center in Medford, Asante Three Rivers Medical Center in Grants Pass, Asante Physician Partners, and additional healthcare partnerships throughout the region.
At Asante we believe that we are defined by our values the traits that guide us as we serve patients and the community:
Excellence - Respect - Honesty - Service Teamwork
Asante is an equal opportunity employer. We are committed to employ and advance in employment women, minorities, qualified individuals with disabilities and protected veterans.