RN Clinical Documentation Specialist - HIM - Clinic

Company: CHI St. Luke's Health - Patients Medical Center
Location: Pasadena
Posted on: September 19, 2023

Job Description:

RN Clinical Documentation Specialist - HIMOverview

Patients Medical Center (PMC) 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 services-wound care, general surgery, gastroenterology, occupational health, heart and vascular, women's services, diagnostic imaging, outpatient rehab services, and sleep disorders.

RN Clinical Documentation Specialist - Health Information Management

Responsibilities

Job Responsibilities for RN Clinical Documentation Specialist

* 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
* Initiates CDMP severity Worksheet for inpatients
* Formulate clinically credible documentation clarifications
* Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety
* Effective and appropriate communication with physicians
* Timely follow-up on all cases and resolution of those with clinical documentation clarifications
* Participate in Task Force Meetings
* Manage multiple priorities
* Communicates with HIM staff and resolves discrepancies
* Accurate input of data into CDMP Trak

Qualifications

Required Qualifications

Education and Licensure

* High School Diploma/GED
* Registered Nurse (RN)

Minimum Experience

* Five (5) years of adult acute care experience in med/surg, critical care, emergency room, or PACU

Minimum Knowledge, Skills, and Abilities

* Ability to learn/develop the skills necessary to perform CDMP
* Organizational, analytical, writing, and interpersonal skills
* Dependable, self-directed and pleasant
* Critical thinking, problem-solving, and deductive reasoning skills
* Knowledge of Pathophysiology and Disease Process
* Basic Computer skills - familiarity with Windows-based software programs
* Knowledge of the regulatory environment

Join us at Catholic Health Initiatives, and become a part of our faith-based health system.

Keywords: CHI St. Luke's Health - Patients Medical Center, Pasadena , RN Clinical Documentation Specialist - HIM - Clinic, Healthcare , Pasadena, Texas