Clinical Documentation Specialist (2026-0294)

Job Title Clinical Documentation Specialist Requirements Req: 2026-0294 Location: VMC Main Campus, Renton, WA Shift: Days Monday–Friday Type: Full Time, FTE: 1 Category: Professional Salary Range: Min $94,894 – Max $142,341/annual DOE Job Overview The Clinical Documentation Specialist facilitates accurate documentation for severity of illness and quality in the medical record. The role involves extensive record review, interaction with physicians, HIM professionals, and nursing staff, and active participation in team meetings and staff education on documentation improvement. Responsibilities Review EMR for completeness and accuracy for severity of illness and quality using documentation strategies. Perform accurate and timely record reviews. Recognize opportunities for documentation improvement. Initiate severity worksheet for inpatients. Formulate clinically credible documentation clarifications. Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety. Communicate effectively with physicians. Follow up on all cases promptly and resolve those with clinical documentation clarifications. Coordinate with HIM staff and resolve discrepancies. Accurately input data for case reconciliation. Provide necessary information and education to physicians and staff to facilitate documentation goals. Identify barriers to completion of documentation goals and intervene appropriately. Review regulations and coding guidelines through seminars, meetings, and materials. Present education sessions to physicians and other providers regarding documentation regulations and chart audit findings, in cooperation with the director of PFS/HIM. Maintain confidentiality of all accessible patient financial or medical records information. Demonstrate awareness of cost containment and provide suggestions for process or quality improvement opportunities to the department manager. Complete other duties as assigned to facilitate accurate, timely patient account management. Qualifications Current unrestricted WA State Registered Nurse license, required. Bachelor's degree in Nursing, preferred. Minimum five years recent clinical experience as an RN in acute care or utilization review. Pass a pre‑hire Clinical Exam with a minimum score of 70%. Effective communication with providers. Knowledge of hospital clinical practice standards for physicians and other health care providers. Knowledge of ancillary service departments, quality control, and safety standards. Critical thinking, problem solving, and deductive reasoning skills. Familiarity with health care audit and research design. Knowledge of pathophysiology and disease processes. Functional knowledge of DRG coding systems. Experience with utilization review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies. Knowledge of third‑party payer review, reimbursement systems, and utilization monitoring requirements for acute care facilities. Meet productivity guidelines. Ability to learn and develop the skills necessary to perform and meet goal standards. Organizational, analytical, writing, and interpersonal skills. Dependable, self‑directed, and pleasant. Basic computer skills—familiarity with Windows‑based software programs. Knowledge of the regulatory environment. Understand and support documentation strategies upon completion of training. Knowledge of core measure and patient safety indicators upon completion of training. Other Information Grade: NC11 | FLSA: E | Cost Center: 8490 Application Deadline Position last updated 7/22; not indicated as expired. #J-18808-Ljbffr Valley Medical Center