Clinical Documentation Specialist-RN

Clinical Documentation Specialist-RN

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation's largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 158 hospital-based locations, in addition to its home-based services and virtual care offerings.

The posted compensation range of $39.18 - $52.00/hour is a reasonable estimate that extends from the lowest to the highest pay CommonSpirit in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.

As a Clinical Documentation Specialist RN, you will be responsible for facilitating accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the CDMP process is a key role.

Every day, you will leverage your expertise to provide individualized, comprehensive care, making critical assessments, performing skilled procedures, and meticulously implementing patient care plans. You'll collaborate seamlessly within an interdisciplinary team, contributing to a dynamic environment focused on optimal patient outcomes.

To be successful in this position you will:

• Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies
• Accurate and timely record review
• Recognize opportunities for documentation improvement
• Formulate clinically credible documentation clarifications
• Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety

Job Requirements We are looking for a responsible and compassionate Registered Nurse with top-notch clinical skills, a caring attitude, and the ability to work independently with minimal supervision. It is also important to display excellent verbal and written communication and interpersonal skills as well as the ability to effectively educate patients and their families on the in-home healthcare process.

• Current Registered Nurse (RN) license that allows you to practice in our state
• Graduate of an accredited nursing program
• Five (5) years of adult acute care experience in med/surg, critical care, emergency room, or PACU
• High school diploma or GED

St. Luke's Health - Patients Medical Center provides inpatient and outpatient medical and surgical services to residents of Pasadena, Deer Park, La Porte, Baytown, and Clear Lake. The facility includes 53 medical/surgical beds, eight ICU beds and three endoscopy rooms, and offers a range of primary and specialized serviceswound care, general surgery, gastroenterology, occupational health, heart and vascular, women's services, diagnostic imaging, outpatient rehab services, and sleep disorders.

CommonSpirit Health is an Equal Opportunity/Affirmative Action employer committed to a diverse and inclusive workforce. All qualified applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, marital status, parental status, ancestry, veteran status, genetic information, or any other characteristic protected by law. For more information about your EEO rights as an applicant, please click here [PDF].

CommonSpirit Health will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c). External hires must pass a post-offer, pre-employment background check/drug screen. Qualified applicants with an arrest and/or conviction will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, ban the box laws, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances. If you need a reasonable accommodation for any part of the employment process, please contact us by telephone at View phone number on click.appcast.io and let us know the nature of your request. We will only respond to messages left that involve a request for a reasonable accommodation in the application process. We will accommodate the needs of any qualified candidate who requests a reasonable accommodation under the Americans with Disabilities Act (ADA). CommonSpirit Health participates in E-Verify.