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RN Clinical Documentation Specialist

Company: Sonoma County Entities
Location: Santa Rosa
Posted on: January 9, 2019

Job Description:

We are looking for a RN Clinical Documentation Specialist - SNA (Staff Nurses Association) for our Health Information Services department at Santa Rosa Memorial Hospital!

Location: Santa Rosa, CA

Schedule: Full-time, 80 standard hours bi-weekly

Shift: 8-hour, Day


The Clinical Documentation Specialist is responsible for supporting and facilitating the overall quality improvement process of medical record documentation by improving the completeness, accuracy, and reliability of clinical documentation Santa Rosa Memorial Hospital. A key success factor of this process is through educating providers and supporting them with improved processes and feedback to accurately reflect patient care in the medical record. Provider feedback is conveyed through attending practice group meetings, medical directors and formal medical staff committees regarding the status and trends of the integrity of their documentation. In partnering with the coding team, this resource will be an expert with ICD-9/ICD-10 content and a leader with physician education and engagement.

Their primary responsibility will be to obtain appropriate clinical documentation through extensive review of provider, nursing staff, ancillary, and other patient care givers documentation, to ensure that appropriate reimbursement is received for the level of services rendered to patients Santa Rosa Memorial Hospital. The Clinical Documentation Specialist (CDS) ensures the clinical information utilized in profiling and reporting outcomes is complete and accurate. An additional goal will be to spend face-to-face time with the providers and quickly help the providers understand their specific ICD-9/ICD-10 impacts and steps to take to improve their documentation. On an ongoing basis is responsible for supporting the direction and focus of education for providers, Provider Specialists, and the coding staff that support various ministries within the region. The CDS exercises independent judgment and discretion within agreed upon limitations and takes actions as needed based on knowledge of the organization, its policies, procedures, and personnel .


Facilitates appropriate clinical documentation to ensure that the overall quality, level of services, severity of illness, and acuity of care are accurately reflected in a complete medical record, yielding the appropriate reimbursement for the level of services rendered and resources consumed.

Performs admission and continued stay reviews, considering clinical issues with coding staff and ministry specific CDI team to assign a working/CDS DRG, based on a proficient knowledge of documentation requirements and guidelines in accordance with Coding Clinics and SJHS compliance.

Provides updated data and information to providers regarding clinical documentation physician education opportunities, coding and documentation issues, and performance improvement opportunities. In collaboration with the Provider Specialists, conducts on-site provider education events/opportunities and align with the CDI program to review targeted opportunities for provider training opportunities.

Utilize the ICD-10 Compass tool and other resources to validate documentation concepts necessary in ICD-9/10 documentation for the CDI team, clinical teams, and providers.

Supports providers in maintaining an updated problem list in Meditech.

Supports the development of new workflows that help imbed documentation concepts into the providers daily work (i.e. problem list, orders, 3rd Party Application such as ePREOP and Iodine) and assists with the education of these tools and workflows to maximize compliance.

Be a positive contributor in how documentation will affect the Hospital Value-Based Purchasing (VBP) results, how patients are included in the Potentially Preventable Readmissions (PPR), and to identify those conditions that may be Hospital Acquired Conditions (HAC) vs. Present on Admission (POA) conditions, and penalties will be associated with lack of proper documentation.

Maintain dynamic communication with coders to identify root cause of CDI-Coder final DRG mismatch and seek to resolve incongruence with appropriately assigned final DRG.

Analyze provider data in concurrence with the Provider Specialist, looking for individual, group, and peer outlier trends that could benefit from additional education. Convey support and education as needed to providers focused on improving processes and the quality of their documentation on a case-by-case basis to accurately reflect patient care in the medical record.

Provider feedback may be distributed through face-to-face education, attending practice group meetings, medical directors and formal medical staff committees regarding the status and trends of the integrity of their documentation.

Additional Responsibilities:

Improves the overall quality and completeness of clinical documentation by using clinical documentation guidelines as needed for secondary review for identifying data trends and educates providers one-on-one and in group sessions on documentation gaps and findings associated with secondary review of low SOI/ROM mortality cases

Utilize CDI team metrics of provider quality and quantity of responses to queries, identifying repeating clinical themes. Create targeted evidenced based education material such as for those providers who receive the greatest volume of queries, with the goal to transition their reactionary charting to proactive documentation.

Working with regional CDI management and Provider Specialist to establish meetings with providers and specialty groups to discuss metrics associated with their current documentation risks/habits and opportunities

Assist in developing ICD-10 compliant queries for the CDI program and actively contribute suggested edits to keep the ICD-10 query resource library up to date.

Providing on-site support and clinical education enhancement on ICD-9/ICD-10 to the coding team

Participate in collaborative calls with the CDI teams on the development of ICD-10 compliant queries and provide clinical feedback to coding team.

Reviews clinical findings and coding clinics with coding staff to assign a working DRG.

Assists in the referral and investigation of quality and risk management issues. Demonstrates understanding of patient rights/confidentiality and legal and ethical issues pertaining to them.

Identifies learning needs of multidisciplinary staff regarding clinical documentation for the health care team and participate in development and implementation of in-services and resources materials to offer education.

Conducts follow-up reviews of clinical documentation to ensure points of clarification with the local providers have been recorded in the patients chart.

Maintains positive open communication with system-wide CDI leadership, regional CDI management, local CDI team, interdisciplinary care team members and department manager.

Serves as a member of the system-wide CDI team and participates in the scheduled meetings.

Knowledge / Skills / Abilities:

Excellent verbal and written communication skills and an expert at interpersonal communication (verbal, non-verbal, and listening skills)

Knowledge of coding classifications systems such as, but not limited to, ICD-9-CM, MS-DRG, APR-DRGs, and HCCs strongly preferred.

Knowledge of ICD-10 and its impact on providers and CDI staff practices

Ability to collects, analyzes, and interpret data (CDI) for physician endorsement of program initiatives

Ability to facilitate understanding, compliance, and completeness in documentation

Work performance goals embrace achieving best practice metrics for compliance and workflows that include multidisciplinary team processes for CDI and Coding staff.

Knowledge of the healthcare revenue cycle.

Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching.

Knowledge of physical and psychological characteristics of illness and medical terminology.

Knowledge of age related developmental stages and needs.

Advanced clinical expertise with an in depth understanding of anatomy and physiology

Extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting.

Proficiency in influencing medical staff changes in documentation

Proficiency in negotiation of complex systems to affect change.

Knowledge of Medicare Part A.

Demonstrates clinical knowledge skills/abilities for the patient population served.

Ability to work collaboratively on a team.

Ability to work independently and make decisions.

Excellent organizational skills.

Ability to work effectively under pressure due to changing priorities, interruptions, high and low census, and payer population work list changes.

Minimum Qualifications:

Education: Associate of Science Degree in Nursing (RN)

Experience: 2 years recent experience in the acute inpatient hospital setting

License / Certification:

Current California RN nursing license (RN)

Preferred Qualifications:

Bachelor of Science degree in Nursing, healthcare administration, or related field

CCDS, CCS, or Clinical Documentation Improvement Professional (CDIP) credentials

2 years working in an inpatient setting as a Clinical Documentation Specialist


The people of St. Joseph Health have worked for 53 years to improve health and quality of life in California's North Bay region, starting in Sonoma County, where the Sisters of St. Joseph of Orange opened the doors of Santa Rosa Memorial Hospital in 1950. Today, we continue the mission begun by the Sisters and continued through the St. Joseph Health Ministry of extending the healing ministry of Jesus to those we serve through an integrated spectrum of primary, urgent, acute, outpatient, palliative care and regional referral services. Sonoma County entities aligned with St. Joseph Health include the 278-bed Santa Rosa Memorial Hospital, the region's only Level II trauma center, as well as the 80-bed Petaluma Valley Hospital. Our services also encompass three Urgent Care centers, Hospice of Petaluma, Memorial Hospice and North County Hospice, the Annadel Medical Group, as well as the St. Joseph Home Care Network. We act as a regional referral hub for outlying hospitals, while also providing outpatient behavioral health care, education to promote health and prevent chronic disease, rehabilitation, oral health care, community benefit programs, and more, all fostering health and quality of life throughout the area.

St. Joseph Health provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, St. Joseph Health complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training..

Positions specified as on call/per diem refers to employment consisting of shifts scheduled on as as needed basis to fill in for staff vacancies.

Keywords: Sonoma County Entities, Santa Rosa , RN Clinical Documentation Specialist, Healthcare , Santa Rosa, California

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