Clinical Documentation Specialist Full-Time Case Management
CHRISTUS St. Vincent
490A West Zia Rd
Santa Fe, NM 87505
The clinical documentation specialist collaborates extensively with physicians, nursing staff, other patient caregivers and coding staff to improve the quality and completeness of documentation of care provided and coded for coordination, abstraction, and submission of accurate data required by CMS. Facilitates concurrent modifications to clinical documentation to insure commensurate reimbursement of clinical severity and services rendered to patients with a DRG based payer (Medicare, Medicaid). Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes. Communicates with and educates all clinical staff concerning accurate and effective clinical documentation
EDUCATION: RN; Graduate of accredited school of nursing. BSN preferred.
CERTIFICATION/LICENSES: Licensed as a Registered Nurse in the State of New Mexico. BLS certification issued through American Heart Association, required.
EXPERIENCE: Minimum of 5 years recent experience in an acute care setting in a clinical nursing field required. Prior experience in clinical documentation improvement, utilization review/management, discharge planning, quality management, case management or coding preferred.
NATURE OF SUPERVISION:
-Responsible to: Director of Case Management Services
ENVIRONMENT: Bloodborne pathogen: A
General office environment and general hospital department/nursing units.
PHYSICAL REQUIREMENTS: Ability to walk and stand 80% of work time.
Each Associate, regardless of position, is expected to act in keeping with CHRISTUS St. Vincent's (CSV) mission. Associate's performance will be evaluated upon the following:
Attendance: Follows attendance and tardiness procedures.
Educational Requirements: Completes all annual educational requirements in a timely manner.
Regulatory Compliance: Maintains regulatory requirements (JCAHO, HIPAA, OSHA, CAP, DHH, Infection Control, and Safety).
Dress Code: Follows dress code and appearance standards; appearance is neat and clean. Wears identification badge, with name and picture showing, while on duty.
Department Meetings: Attends a minimum of 80% of staff meetings annually; reads all meeting minutes.
Safety: Follows necessary and pertinent safety precautions during the performance of job duties, to prevent injury to self and/or others and to prevent damages to hospital equipment/property.
HIPAA: Follows the CHRISTUS Health guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of a patient's Protected Health Information (PHI).