RN Clinical Documentation Specialist - HIM

Overview

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

Responsibilities

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

Qualifications

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.