RN-Clinical Documentation Specialist - Eisenhower Health : Job Details

R0268241 * *Job Objective:* A brief overview of the position. * Facilitates clinical documentation improvement through extensive daily interaction with physicians, caregivers, case management and coding staff to achieve timely, accurate, and complete documentation. In doing so, provides on-going physician/provider education and consultation to improve the accuracy, completeness, specificity and compliance of the in-patient acute care Medical Record. Educates physicians/providers, RNs and other healthcare disciplines in understanding the importance of accurate documentation that reflects EMC's patient population as it is related to severity of illness and risk of mortality. * *Reports to* * DIRECTOR, CASE MANAGEMENT * *Supervises* * None * *Ages of Patients* * Pediatric * Adolescent * Adult * Geriatric * *Blood Borne Pathogens* * Minimal/ No Potential * *Qualifications * * *Education* * Required: BSN or MSN or enrollment in an RN-BSN or RN-MSN program within 1 year of hire and completion within 5 years of hire if hired after July 1, 2012 * *Licensure/Certification* * Required: Active California RN license * Preferred: CCS, RHIT, ICD-10 AHIMA training certification or equivalent * *Experience * * Required: A minimum of 5 years recent clinical nursing experience in an acute care setting. * Preferred: Knowledge of MS-DRG methodology and inpatient coding rules and regulations * *Essential Responsibilities* * Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations. * Performs concurrent review of medical records and identifies areas of documentation requiring clarification of comorbidities, presence of complications and the presence of an opportunity to improve documentation from the physician to accurately assign the best DRG. * Reviews 25-35 records in assigned areas within 24 hours or first working day after admission and with evidence of ongoing record review at least every 48 hours when necessary. * Compiles data in Midas and maintains monthly and Quarterly records of outcomes that reflect improvement in Clinical Documentation Improvement financial performance. Tracks and reports financial and statistical data in designated system. Prepares monthly and quarterly reports for Director of Case Management * Communicates with and works collaboratively with coding personnel to determine outcomes regarding severity/complexity and to assure all opportunities have been pursued before patients' discharge from acute care setting. * Educates physicians and staff on Query tool as it relates to quality of documentation in the medical record. * Reviews all defined medical records to identify laboratory, radiology, cardiac & pulmonary information and procedures pertinent to the patient's care that is not clearly documented in the medical record. * Analyzes deficiencies and educates physicians in need for appropriate documentation to capture the complexity of care and the severity of illness. * Implements tracking systems to measure the effectiveness of education. * Develops and tracks, in cooperation with the coding department, outcomes related to education and follow-through by physicians regarding accurate complication/comorbidity documentation. * Interfaces with physician champion regarding educational opportunities for specific documentation with physicians identified as needed additional education. * Develops and updates pertinent policies and procedures and processes in collaboration with the Director of Case Management. * Obtains daily census and tracks defined admissions and discharges. * Maintains compliance to HIPAA and all other regulations related to patient confidentiality. * Educate nursing, ancillary, case management staff, and appropriate committees regarding the Clinical Documentation Improvement process and outcomes. * Communicate with team members and participate in appropriate committees to report outcome information. * Collaborate with the Utilization Management Specialist when continued stay or level of care issues are identified. * Assist the HIM department in facilitation of the physician query process after patient discharge. * Performs special projects and other duties as directed. []( []( [](There's no better place to live, work, play, and prosper. At our award-winning medicalfacilities located in the Coachella Valley, you'll be part of a five-star team with othertop health care professionals.In 2024, we were honored to be named to Forbes' prestigious America's BestEmployers List for the third time, a testament to our dedication to providing anexceptional work environment. Eisenhower Health is the sole employer in theCoachella Valley to receive this esteemed designation, solidifying our reputation asan outstanding place to build a career.Our dedication to delivering high-quality, compassionate medical care is evident inour rankings. According to U.S. News & World Report, we hold the esteemed positionof #1 in the Inland Empire and #12 in California among hospitals. Our Magnetrecognition underscores our commitment to nursing excellence and quality patientcare.Our commitment to excellence extends beyond awards; we are the only hospital inRiverside County to have received a five-star rating three years in a row in the USAGovernment Rating System, a distinction awarded to just 10% of hospitalsnationwide.We take pride in fostering an inclusive environment for all. With a score of 95 out of100, we have been designated as an LGBTQ+ Healthcare Equality Top Performer bythe Human Rights Campaign, highlighting our dedication to providingcompassionate care to all members of our community.Our commitment to patient safety is unwavering, as demonstrated by our A gradein the Leapfrog Hospital Safety Grade for Spring 2023.At Eisenhower Health, we don't just set standards; we raise them. Join our team andbe part of an organization that is consistently recognized for excellence in healthcare and workplace satisfaction. Your career at Eisenhower Health will be marked bygrowth, innovation, and the opportunity to make a meaningful impact on the lives ofour patients and the community we serve. Eisenhower Health is an equalopportunity employer.