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    Clinical Documentation Specialist - San Francisco, United States - CPMC-California Pacific Med Center Van Ness

    CPMC-California Pacific Med Center Van Ness
    CPMC-California Pacific Med Center Van Ness San Francisco, United States

    3 weeks ago

    Default job background
    Full time
    Description

    Position Overview:

    Conducts concurrent and retrospective reviews of patient medical records to evaluate the accuracy and completeness of clinical documentation, ensuring notes reflect the severity of patient's illness and quality of care. Interacts thoughtfully and effectively with physicians, patient care team, and ancillary departments to gather and clarify medical record documentation. Identifies opportunities for improvement to ensure understanding of documentation requirements, optimize reimbursement for the level of service rendered, and enhance the measurement and reporting of outcomes.

    Job Description :

    EDUCATION
    Equivalent experience will be accepted in lieu of the required degree or diploma.

    Bachelor's: Nursing, Health Information Management, Healthcare Administration or related field. or equivalent education/experience

    PREFERRED EXPERIENCE AS TYPICALLY ACQUIRED IN:

    5 years experience with progressive responsibility in clinical documentation improvement, patient care delivery, and/or medical records coding.

    5 years experience in clinical acute care and/or ambulatory setting.

    5 years experience with diverse patient population.

    SKILLS AND KNOWLEDGE

    Clinical knowledge of diagnoses, severity of illness, risk of mortality, co-morbidities and complications.

    Knowledge of age-specific needs and the elements of disease processes and related procedures.

    Knowledge of current coding classification and reimbursement guidelines and regulations.

    Critical thinking with the ability to analyze and interpret medical record/clinical documentation and formulate appropriate physician queries.

    Ability to define issues, collect data, establish facts and draw valid conclusions.

    Demonstrates a proactive approach in identifying and addressing issues and concerns.

    Collaboration skills to facilitate open sharing of information and cooperation with various stakeholders to problem solve and achieve desired results/outcome.

    Displays a customer service focus in all decisions and actions.

    Ability to communicate through verbal and written means, and to present information to a variety of audiences.

    Ability to create and translate data into reports and presentations for appropriate audience.

    Organization skills to effectively manage and/or re-prioritize activities and projects to meet deadlines wihle maintaining a high degree of responsiveness.

    Ability to interact and maintain effective working relationships with those contacted in the performance of required duties.

    Demonstrates respect for cultural and linguistic differences and promotes an inclusive work environment.

    Demonstrates initiative in providing feedback/input to improve workflow/processes.

    Ability to work effectively in a dynamic and fast-paced environment with changing business priorities.

    Ability to maintain and work discreetly with confidential information.

    Ability to use essential applications and/or databases associated with the role's duties and responsibilities.

    Pay Range: $57.94-$86.91/hour

    Job Shift :

    Days

    Schedule:

    Full Time

    Shift Hours:

    8

    Days of the Week:

    Variable

    Weekend Requirements:

    None

    Benefits:

    Yes

    Unions:

    No

    This position is work from home eligible.

    Position Status:

    Non-Exempt

    Weekly Hours:

    40

    Employee Status:

    Regular

    Number of Openings:

    1

    Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

    Pay Range is $59.82 to $89.73 / hour

    The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate's experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.

    Qualified applicants with arrest and conviction records will be considered for employment. Applicants for specific positions are still required to disclose certain convictions during the application process, and those convictions may also be considered in determining eligibility for employment in accordance with applicable law.

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