Nurse Clinical Documentation - RN

Clinical Documentation Specialist

Salary Range $41.29 - $64.61 Overview

Located in the heart of Washington, we enjoy open skies, snow-capped mountains, and the lakes and rivers of the high desert. We are the proud home of orchards, farms, and small communities. Confluence Health actively supports the communities we serve and their quality of life through our community support program and through our individual efforts as involved community members.

Pool Employees of Confluence Health receive a range of benefits in addition to compensation.

• Retirement Plan
• Pool Differential
• Sick Leave
• Shift Differential
• Employee Assistance Program

Summary

Please note: This is a pool position. No guarantee of hours.

The CDS is responsible for facilitating a thorough, complete and accurate patient health record which will secure the correct reimbursement for resource utilization, the highest quality measures and outcomes, superior communication between providers, and ultimately high patient satisfaction. Travel may be required to outlying clinics. Work is conducted remotely, in the hospital and/or in the clinic.

Position Reports To: Director of Quality Analytics

Essential Functions

1. Ability to learn and develop the skills necessary to perform clinical documentation reviews using the tools provided.
2. Perform accurate and timely record review.
3. Recognize opportunities for documentation improvement.
4. Formulate clinically credible documentation clarifications.
5. Effectively communicate opportunities for clarification to providers in a way that secures complete and accurate documentation.
6. Effective and appropriate communication with providers, the clinical documentation and coding teams, and others that fosters collaboration and trust.
7. Timely follow-up on all clarification requests.
8. Participate in Task Force meetings.
9. Manage multiple priorities.
10. Adhere to established clinical documentation rules, processes and workflows.
11. Apply critical thinking, problem solving, and deductive reasoning skills to complex clinical and interpersonal situations.
12. Understand and communicate differences between IPPS and OPPS and how they impact DRGs and ICD-10 code assignment.
13. Able to process multiple sources of information simultaneously while maintaining clarity of thought and purpose.
14. Required to maintain active Basic Life Support (CPR) certification.
15. Performs other duties as assigned.

Demonstrate standards of behavior and adhere to the Code of Conduct in all aspects of job performance at all times.

Qualifications

Required :

• Recent 2 years acute care experience, preferably ICU, PCU or strong Med/Surg.
• Current licensure in the state of Washington (RCW 18.88) or licensure through Multistate Nurse Licensure Compact (SSB 5499).
• Must successfully pass an on-line clinical knowledge assessment (provided by Confluence Health) with 70% or greater.
• Extensive knowledge of pathophysiology, disease processes and associated care-pathways.
• Basic computer skills; familiarity with Microsoft software programs.

Desired :

• BSN.
• 5 years acute care experience
• Experience in organizational, analytical, and writing skills.
• ACDIS or other national CDI certification.
• Knowledge of CMS and regulatory environment.

Physical/Sensory Demands

O = Occasional, represents 1 to 25% or up to 30 minutes in a 2 hour workday.

F = Frequent, represents 26 to 50% or up to 1 hour of a 2 hour workday.

C = Continuous, represents 51% to 100% or up to 2 hours of a 2 hour workday.

Physical/Sensory Demands For This Position:

• Walking - C
• Sitting/Standing - C
• Reaching: Shoulder Height - O
• Reaching: Above shoulder height - O
• Reaching: Below shoulder height - O
• Climbing - O
• Pulling/Pushing: 25 pounds or less - O
• Pulling/Pushing: 25 pounds to 50 pounds - O
• Pulling/Pushing: Over 50 pounds - O
• Lifting: 25 pounds or less - O
• Lifting: 25 pounds to 50 pounds - O
• Lifting: Over 50 pounds - O
• Carrying: 25 pounds or less - O
• Carrying: 25 pounds to 50 pounds - O
• Carrying: Over 50 pounds - O
• Crawling/Kneeling - O
• Bending/Stooping/Crouching - O
• Twisting/Turning - C
• Repetitive Movement - C

Working Conditions:

• Work is done throughout a specific clinical/reception area of the building. Some work areas may be small, crowded, and confined. Job requires both working closely with others and working alone. Hours can vary from a normal schedule and overtime may be required. Stressful working conditions do exist.

Job Classification:

• FLSA: Non-Exempt
• Hourly/Salary: Hourly

Physical Exposures For This Position:

• Unprotected Heights - No
• Heat - No
• Cold - No
• Mechanical Hazards - No
• Hazardous Substances - No
• Blood Borne Pathogens Exposure Potential - Yes
• Lighting - Yes
• Noise - No
• Ionizing/Non-Ionizing Radiation - No
• Infectious Diseases - Yes