Clinical Documentation Integrity Specialist

Creating Life Better Here starts with you. At San Juan Regional Medical Center, we're more than a healthcare provider—we're a values-driven organization dedicated to delivering exceptional care. As a team member, you help fulfill our mission to make life better here for our community.

Facilitates improvement in the quality and completeness of patient records on a concurrent basis, using a multi-disciplinary process. Applies clinical knowledge and coding knowledge to evaluate clinical indicators, diagnoses, and treatment plan for assigned inpatients, to identify gaps in physician documentation.

Behaviors:

• As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization: Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.

Required Qualifications:

• Registered Nurse - Minimum of three (3) years strong clinical background in acute care
• Current NM Licensure
• Excellent written and verbal communication skills
• Analytical thinking skills
• Team-oriented
• Basic computer skills
• Highly organized

Preferred Qualifications:

• BSN
• Certified Clinical Documentation Specialist (CCDS)
• Coding experience

Duties and Responsibilities:

• Comprehensively reviews patient records, concurrently and retrospectively, to assure a complete and accurate representation of the severity of illness and use of resources.
• Assigns Working DRG
• Works closely with physicians, Case Management staff, and Coding to review documentation coding practices analyzing whether documentation supports the acuity of the patients.
• Identifies gaps in physician documentation and facilitates appropriate documentation improvement interventions with physicians.
• Identifies Clinical Documentation Improvement (CDI) best practices, benchmarks and improvement strategies to augment compliance objectives.
• Stays current on information pertaining to coding, compliance, clinical guidelines and payer requirements as it relates to MSDRG assignment, documentation and other payment requirements.
• Each employee is responsible for implementing SJRMC’s Service Standards into their daily work:

                                                     Safety, Courtesy, Effectiveness, and Stewardship

• Other duties as assigned

Physical Demands and Environmental Work Conditions:

• Prolonged standing/sitting/walking
• Fast paced environment
• High level of activity with many interruptions
• Possible exposure to communicable disease
• Repetitive motions (i.e.; keyboard usage)

Sensory Requirements:

The employee will need to be able to hear:

• Alarms on equipment/fire alarms/overhead announcements
• Patients/family/physician verbal discussion
• Feedback from other healthcare providers

The employee will need to be able to see:

• Focus on close-up and distant objects
• Have intact: peripheral vision and depth perception