Clinical Documentation Specialist
St. Charles Health SystemAbout the role
In addition, this role is eligible to work remotely from an approved state by St. Charles (please refer to the list). If you do not reside in an approved listed state (or do not plan to relocate to an approved listed state) we request, you do not apply for this particular position.
Approved states by St. Charles: Oregon, Arizona, Arkansas, Florida, Idaho, Missouri, Montana, Nevada, New Mexico, North Carolina, Oklahoma, Tennessee, Utah, and Wisconsin.
About St. Charles Health System:
St. Charles Health System is a leading healthcare provider in Central Oregon, offering a comprehensive range of services to meet the needs of our community. We are committed to providing high-quality, compassionate care to all patients, regardless of their ability to pay. Our values of compassion, excellence, integrity, teamwork, and stewardship guide our work and shape our culture.
What We Offer:
Competitive Salary
Comprehensive benefits including Medical, Dental, Vision for you and your immediate family
403b with up to 6% match on Retirement Contributions
Generous Earned Time Off
Growth Opportunities within Healthcare
ST. CHARLES HEALTH SYSTEM
JOB DESCRIPTION
TITLE: Clinical Documentation Integrity Specialist II
REPORTS TO POSITION: Manager, Clinical Documentation
DEPARTMENT: Quality
DATE LAST REVIEWED: April 2023
OUR VISION: Creating America’s healthiest community, together
OUR MISSION: In the spirit of love and compassion, better health, better care, better value
OUR VALUES: Accountability, Caring and Teamwork
DEPARTMENT SUMMARY: The Clinical Documentation Department performs concurrent and selected retrospective medical record reviews in order to facilitate appropriate provider documentation that captures the most complete and accurate clinical conditions impacting patient visits.
POSITION OVERVIEW: The Clinical Documentation Integrity Specialist II at St. Charles Health System provides clinical based review and analysis of the documentation in the patient’s medical record to support accurate capture of patient’s complexity and severity of illness. Utilizes queries of the medical staff and other caregivers to clarify and support completeness of documentation.
This position does not directly manage any other Caregivers.
ESSENTIAL FUNCTIONS AND DUTIES:
Collaborates with physician, mid-level providers, ancillary staff, and medical records coders to identify principle and secondary diagnoses, and principle procedures. Also reviews for quality indicators.
Maintains current knowledge of Medicare’s rules, regulations, and guidelines.
Conducts initial and ongoing concurrent and some retrospective reviews for system wide admissions for all payors, initiates tracking process, and documents findings on EHR tracking system.
Identifies when there is a need to clarify documentation in patient records and initiates queries or communication with providers to capture accurate documentation of the patient’s severity of illness and risk of mortality in compliance with all guidelines and requirements.
Provides information and education as necessary to providers on an ongoing basis. Collaborates with Physician Advisor to present specialty specific and/or individual education. Independently attends provider service line meetings or team meetings to serve as a resource and/or educate on documentation opportunities.
Volunteers for special projects in the department such as developing education materials/presentations, tip sheets, present teaching opportunities to co-workers, etc.
Complies with all applicable laws, regulations, policies and procedures, supporting the health system’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violations of applicable rules, and cooperating fully with all company investigations and proceedings.
Supports the vision, mission, and values of the organization in all respects.
Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
Provides and maintains a safe environment for caregivers, patients, and guests.
Conducts all activities with the highest standards of professionalism and confiden
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