Clinical Documentation Specialist
This is a full time position working at Northwest Medical Center.
As a Northwest Healthcare system employee, this individual implements clinical documentation improvement (CDI) activities at assigned CHS facilities to ensure that coded diagnoses are an accurate reflection of the patient’s clinical status and care. Reviews medical record documentation and clinical indicators and works with providers to ensure a complete and accurate medical record. Identifies potential gaps in clinical documentation for inpatient and payer populations as directed throughout the hospitalization. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
Position Qualifications/Minimum Requirements
ADN or Diploma in Nursing Program, BSN preferred.
Required: Five years of acute hospital nursing experience (e.g. medical/surgical unit, intensive care).
Preferred: Experience in Utilization Management/Case Management, Critical Care, patient outcomes/quality management and/or inpatient coding, ICU/Critical Care, clinical documentation improvement, ICD coding and MS-DRGs, working in a clinical documentation improvement department or as a consultant and minimum of one (1) year auditing experience.
Comprehensive knowledge of medical terminology, disease processes and clinical competency. Excellent relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills. Ability to educate others about clinical documentation. Data quality and integrity skills. Strong working knowledge of word processing, spreadsheet and reporting software. Experience working with encoder software, clinical documentation improvement software and the electronic medical record.
Required: Current Arizona RN license or compact state license.
Preferred: RHIT, RHIA, CDIP, CDIS, CCDS, CCS and ICD-10 certification or designation.
Northwest Medical Center is comprised of a 300-bed hospital, three urgent care facilities, a freestanding emergency center and a large physician group, offering you a variety of settings in which to work. Every location is dedicated to providing safe, quality patient care, but more than that is the commitment to employees. It strives to provide a culture of teamwork, respect and appreciation for all staff, whether they care for patients directly or work in a support role. With employee appreciation celebrations throughout the year, opportunities for growth and the satisfaction that you are part of a hospital leading the way with accessible, convenient healthcare in Tucson, Northwest is a great place to work. NMC is accredited by The Joint Commission and is an equal opportunity employer: race, gender, disability and Veteran status, and VEVRAA Federal Contractor – priority referral Protected Veterans requested.