CLINICAL DOCUMENTATION SPECIALIST - RN (HOSPITALS)

Scripps Health

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Job Information

Scripps Health Administrative Services supports our five hospitals and 19 outpatient facilities, which treat half a million patients annually through 2,600 affiliated physicians.

At Scripps Health, you will experience the pride, support, and respect of an organization that has been repeatedly recognized as one of the nation’s Top 100 Places to Work.

You’ll be surrounded by people committed to making a difference in the lives of their patients and their teammates. So if you’re open to change, go ahead and unlock your potential.

The primary goal at Scripps Health is to deliver the very best patient experience. Naturally, Scripps Health wants to give our employees every opportunity to grow professorially.

In this role, you will have the opportunity to join the newly expanding Centralized Clinical Documentation team. This unique offer to grow your skills and receive a highly desirable national training program that provides the knowledge and skills to perform at the highest level of a Clinical Documentation Specialist. You will provide concurrent review of the clinical documentation in the inpatient medical record to assist in properly reflecting the patient acuity; review the medical record with a clinical lens to identify any missing or understated diagnoses. Upon completion of the training program, CDI clinicians will be able to leverage their Scripps organizational knowledge and physician relationships to support our patients through the patient medical record reviews. This is the ideal position for someone who thrives in analytical data to solve problems, enjoys physician and coding staff collaboration, while interested in making a transition away from bedside nursing.

As a Clinical Documentation Specialist, you will:

  • Review inpatient records for our five Scripps Health hospitals.
  • Facilitate improvement in medical record documentation by interacting with and educating physicians, nurses and coding staff to ensure medical records accurately reflect patient acuity for quality reporting and insurance reimbursement.
  • Understand the importance that this clinical documentation work has and how it has the prospect to make a large impact enterprise-wide and support a high-quality patient experience.
  • Complete admission reviews and work closely with coding staff to ensure accuracy in code assignments that reflect the patients clinical status and care.
  • Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge.
  • Maintain accurate records of review activities, ensuring reports and outcomes of clinical documentation improvement (CDI) efforts are valid.
  • Provide education to the healthcare team on an ongoing basis regarding documentation opportunities, coding, and reimbursement issues, and relevant quality and performance improvement activities.
  • Provide a concurrent review of the clinical documentation in the inpatient medical record to assist in properly reflecting the patient acuity; review the medical record with a clinical lens to identify any missing or understated diagnoses

This is a Full-Time (80 hours every two weeks) benefited and salaried position working day shifts on Monday - Friday. Located at Scripps Corporate Offices, San Diego.

Required Education/Experience/Specialized Skills:

  • CA RN License or MD required.
  • Experienced in using electronic medical records and computer applications.
  • Excellent communication and critical thinking skills.
  • Strong leadership qualities including the ability to motivate, teach and facilitate individuals and groups on reaching objectives of program.
  • Ability to review and interpret clinical information and knowledge of hospital regulatory requirements desired.
  • Computer literacy and ability to efficiently and effectively obtain clinical information from a variety of sources necessary.

Preferred Education/Experience/Specialized Skills/Certification:

  • Bachelors preferred.

Scripps Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with disability.