| Location | Renton, WA |
JOB DESCRIPTION
The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.
TITLE: Clinical Documentation Specialist RN
JOB OVERVIEW: The Clinical Documentation Specialist provides an essential role in ensuring the medical record accurately reflects the patient''s clinical condition, severity of illness, risk of mortality, quality outcomes, and services provided. The position serves as a liaison between providers, coding professionals, case management, quality, and revenue cycle teams to improve documentation accuracy, support complete coding and billing compliance.
DEPARTMENT: Health Information Management
WORK HOURS: Monday - Friday, typically 7:00 AM - 3:30 PM. Flexibility may be required to meet department and organization needs.
REPORTS TO: Manager, Clinical Documentation Improvement
PREREQUISITES:
Current unrestricted Registered Nurse (RN) license in the State of Washington, required.
Minimum five years recent clinical experience as a Registered Nurse in an acute care inpatient hospital setting, OR minimum of three years of acute care inpatient hospital setting combined with at least one year of inpatient Clinical Documentation Specialist experience, required.
Certified Clinical Documentation Specialist (CCDS) strongly preferred
Clinical Documentation Specialist - Outpatient (CCDS-O) strongly preferred.
Experience in EPIC (Resolute) or similar EHR required.
Proficient in various computer applications, including Microsoft Office, Excel, Word, PowerPoint, Visio, and Outlook.
QUALIFICATIONS:
Understanding of MS-DRGs, APR-DRGs, Severity of Illness (SOI), Risk of Mortality (ROM), Hierarchical Condition Categories (HCCs), and value-based reimbursement methodologies.
Proven ability to build collaborative partnerships with physicians and departments to drive organizational initiatives.
Exceptional organizational and self-management skills, with the ability to prioritize, multitask, and manage multiple projects effectively in a fast-paced, deadline-driven environment.
Effective communicator with ability to facilitate discussions and present clearly to groups.
Ability to remove technical and cultural barriers to achieve operational objectives.
Comprehensive knowledge of disease processes, clinical terminology, anatomy, and physiology.
Familiarity with compliant physician query practices and clinical validation principles.
Comprehensive knowledge of industry standards, regulatory requirements, and best practices to ensure successful project delivery in alignment with departmental objectives.
Excellent organizational and interpersonal skills, including the ability to work collaboratively across departments, in a matrix environment with colleagues at all levels of the organization to achieve strategic goals.
Ability to effectively communicate using verbal, written and presentation form.
Self-motivated and results oriented.
Demonstrate critical thinking, clinical judgment, problem-solving, and deductive reasoning skills.
UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT AND WORKING CONDITIONS:
Must possess ability to work independently, with minimal direction, and take initiative in problem solving.
Must be able to interact professionally and effectively with a wide variety of people, including operations staff, providers, the general public, and departments at Valley Medical Center (VMC).
Attention to detail and excellent organizational skills are essential.
Must be able to function effectively in an environment with frequent interruptions and multiple tasks.
Must be able to effectively interact with patient access and billing systems and other relevant third-party software, create, and maintain spreadsheets, and take and c