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RN Clinical Documentation Specialist

Company: CHI St. Luke's Health–Patients Medical Center
Location: Pasadena
Posted on: October 2, 2021

Job Description:

Overview

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.

 

Facilitates 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.


Responsibilities
  • 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

#missioncritical


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 regulatory environment

Keywords: CHI St. Luke's Health–Patients Medical Center, Pasadena , RN Clinical Documentation Specialist, Other , Pasadena, Texas

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