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RN Clinical Documentation Specialist ...

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RN Clinical Documentation Specialist - HIM

CommonSpirit Health Pasadena, TX (Onsite) Full-Time

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.

RN Clinical Documentation Specialist - Health Information Management


Job Responsibilities for RN Clinical Documentation Specialist
  • 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


Required 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 the regulatory environment

Join us at Catholic Health Initiatives, and become a part of our faith-based health system.

Recommended Skills

  • Analytical
  • Certified Nurse Practitioner
  • Clinical Works
  • Critical Thinking
  • Curiosity
  • Deductive Reasoning

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Job ID: a7efc5b33730ec0771379002c622c015

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