Job Description

Job Description

The position supports all facilities of Northwest Healthcare System As a Northwest Healthcare system employee, this individual implements clinical documentation improvement (CDI) activities at assigned CHS facilities in an effort to support accuracy and quality of the patient records and to ensure that coded diagnoses are an accurate reflection of the patients clinical status and care. The role of the Clinical Documentation Specialist II involves reviewing the medical record documentation and clinical indicators and working with providers to ensure a complete and accurate medical record. An accurate medical record is important for the patient, for continuity of care by the next provider, and to demonstrate high quality care by the physician and the hospital.

Full Time position working 5 days weekly at the Northwest Medical Center facility location

The position supports all facilities of Northwest Healthcare System

Position Purpose

As a Northwest Healthcare system employee, this individual implements clinical documentation improvement (CDI) activities at assigned CHS facilities in an effort to support accuracy and quality of the patient records and to ensure that coded diagnoses are an accurate reflection of the patients clinical status and care. The role of the Clinical Documentation Specialist II involves reviewing the medical record documentation and clinical indicators and working with providers to ensure a complete and accurate medical record. An accurate medical record is important for the patient, for continuity of care by the next provider, and to demonstrate high quality care by the physician and the hospital. The Clinical Documentation Specialist II will identify potential gaps in clinical documentation for inpatient and payer populations as directed throughout the hospitalization. He/she will educate physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record. In addition, this individual will serve as a senior member of the team with responsibility for training others and assisting in senior level daily operational duties.

Position Qualifications/Minimum Requirements

Education:

ADN or Diploma in Nursing Program, BSN preferred.

Experience:

Required: Five years of acute hospital nursing experience (e.g. medical/surgical unit, intensive care).

Two years of acute hospital clinical documentation improvement experience.

Preferred: Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and/or inpatient coding, ICU/Critical Care, ICD coding and MS-DRGs, and minimum of one (1) year auditing experience .

Skills:

Comprehensive knowledge of medical terminology, disease processes and clinical competency. Excellent relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills. Ability to educate others about clinical documentation. Data quality and integrity skills. Strong working knowledge of word processing, spreadsheet and reporting software. Experience working with encoder software, clinical documentation improvement software and the electronic medical record.

Licenses/Certifications:

Required: Current Arizona RN license or compact state license.

At least one current certification in coding or clinical documentation improvement (i.e. RHIT, RHIA, CDIP, CDIS, CCDS, or CCS), may consider without certification with expected completion within one year of hire/transfer into the position.

Northwest Healthcare is a multi-faceted network dedicated to providing safe, quality care at each of our locations. With two (soon to be three) hospitals, two freestanding emergency centers, four urgent care locations and a large physician practice including primary care and a variety of specialists, Northwest Healthcare offers you a wide range of settings in which to work. Common among them all is not only the commitment to providing safe patient care, but to employee satisfaction and growth. It is a culture of teamwork, respect and appreciation for all employeeswhether caring for patients directly or working in a support role. NWHC is accredited by The Joint Commission and is an equal opportunity employer: race, gender, disability and Veteran status, and VEVRAA Federal Contractor priority referral Protected Veterans requested.

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