RN - Clinical Documentation Specialist

Clinical Documentation Specialist

The Clinical Documentation Specialist (CDS) is responsible for supporting and facilitating the overall quality of medical record documentation by improving the completeness, accuracy, and reliability of clinical documentation. A key success factor of this process is educating providers through the query process and independently supporting them with education and feedback to accurately reflect the patient's true clinical picture within the medical record. In partnering with the coding team, the CDS will be an expert with ICD-10, NS-DRG and APR-DRG assignment.

The CDS's primary responsibility will be to obtain appropriate clinical documentation through extensive review of provider, nursing, ancillary, and other patient caregivers' documentation, to ensure that appropriate documentation and reimbursement is received for the level of services rendered to patients. The CDS exercises their judgment and discretion to ensure the clinical information utilized in analyzing and reporting outcomes is complete and accurate. On an ongoing basis, the CDS is responsible for supporting the direction and focus of education for providers and the coding staff within their assigned scope of work. The CDS must exercise independent judgment, critical thinking, ability to work independently while interpreting and following CMS guidelines, organizational policies, and procedures.

Providence caregivers are not simply valued they're invaluable. Join our team at Providence Regional Medical Center Everett and thrive in our culture of patient-focused, whole-person care built on understanding, commitment, and mutual respect. Your voice matters here, because we know that to inspire and retain the best people, we must empower them.

Required Qualifications:

• Associate's Degree - Associate of Science in Nursing.
• Registered Nurse License upon hire.
• 5 years - Experience as an RN in acute care setting within the last 5 years OR 2-3 years Clinical Documentation Integrity experience in acute care setting.

Preferred Qualifications:

• Bachelor's Degree - Bachelor of Science in Nursing or a Bachelor of Science degree in healthcare or other related field.
• 5 years - Hospital experience in ICU, ED or Medical/Surgical
• 1 year - Understanding of MS-DRG and APR-DRG assignment and fundamentals of establishing a DRG.
• 1 year - ICD-10 experience and/or understanding

Why Join Providence?

Our best-in-class benefits are uniquely designed to support you and your family in staying well, growing professionally, and achieving financial security. We take care of you, so you can focus on delivering our Mission of caring for everyone, especially the most vulnerable in our communities.

About Providence

At Providence, our strength lies in Our Promise of "Know me, care for me, ease my way." Working at our family of organizations means that regardless of your role, we'll walk alongside you in your career, supporting you so you can support others. We provide best-in-class benefits and we foster an inclusive workplace where diversity is valued, and everyone is essential, heard and respected. Together, our 120,000 caregivers (all employees) serve in over 50 hospitals, over 1,000 clinics and a full range of health and social services across Alaska, California, Montana, New Mexico, Oregon, Texas and Washington. As a comprehensive health care organization, we are serving more people, advancing best practices and continuing our more than 100-year tradition of serving the poor and vulnerable.

About the Organization

Providence has been serving the Pacific Northwest since 1856 when Mother Joseph and four other Sisters of Providence arrived in Vancouver, Washington Territory. Today, Providence is the largest health care provider in Washington located in communities large and small across the state. In western Washington, Providence provides care throughout the greater Puget Sound from Snohomish County to Lewis County. Our award-winning and comprehensive medical centers are known for outstanding programs in cancer, cardiology, neurosciences, orthopedics, women's services, emergency and trauma care, pediatrics and neonatal intensive care. Our not-for-profit network also provides a full spectrum of care with leading-edge diagnostics and treatment, outpatient health centers, physician groups and clinics, numerous outreach programs, and hospice and home care. Providence is proud to be an Equal Opportunity Employer. We are committed to the principle that every workforce member has the right to work in surroundings that are free from all forms of unlawful discrimination and harassment on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law. We believe diversity makes us stronger, so we are dedicated to shaping an inclusive workforce, learning from each other, and creating equal opportunities for advancement.

Providence Health & Services