The Clinical Documentation Specialist will provide active, concurrent and retrospective review of provider documentation, query for clarification, provide feedback, and educate clinical care providers to improve the documentation of all conditions, treatments and care plans within the health record to accurately reflect the condition of the patient and promote patient care. In addition, the CDS will work with the physicians to ensure high quality documentation that supports accurate representation of the care provided to the patient as reflected through MS-DRG assignment, case mix index, severity of illness, risk of mortality, quality measures, physician profiling, hospital profiling and reimbursement rules.

The CDS exhibits a comprehensive knowledge of clinical documentation requirements, DRG assignment, clinical conditions or procedures, and understanding of coding concepts and guidelines. The CDS is also responsible for communicating and educating members of the patients care team regarding documentation guidelines; and collaborating with other stakeholders throughout OHSU, including Quality; Enterprise Coding; and Integrity.

 

 

• Excellent observation skills, analytical and critical thinking, problem solving with good verbal and written communication skills.
• Knowledge of age specific needs and the elements of disease processes and related procedures for the targeted patient population
• Clinical knowledge and understanding of pathology/physiology of disease processes.
• Strong understanding of reimbursement and coding methodologies and guidelines; MS-DRGs; Severity of Illness, Risk of Mortality, Medical Necessity, Core and Quality Measures and impact of Length of Stay.
• Strong understanding of medical terminology.
• Ability to work independently in time sensitive environment.
• Ability to work as a part of a multidisciplinary team.

• Current unencumbered Oregon RN.
• External applicants- BSN required; Current OHSU employees-BSN preferred; training in Clinical Documentation Improvement through ACDIS or AHIMA.
• Certified Clinical Documentation Specialist (CCDS or CDIP); or certification within 6 months of hire
• Minimum of 3-5 years of experience in acute care nursing (RN); at least 1 year of experience in a Clinical Documentation Integrity program
• Valid Basic Life Support (BLS) certification issued by American Heart Association; Certified Clinical Documentation Specialist (CCDS or CDIP); or certification within 6 months of hire

• 2-3 years of experience in a Clinical Documentation Integrity program with experience in clinical quality, utilization management, case management, or related field

• Comprehensive health care plans. Covered 100% for full-time employees and 88% for dependents.
• $25K of term life insurance provided at no cost to the employee
• Two separate above market pension plans to choose from
• Vacation - 192 to 288 hours per year depending on length of service, prorated for part-time
• Sick Leave - 96 hours per year, prorated for part-time
• Holidays - up to 64 holiday hours per calendar year (employees accrue .0308 holiday hours for each hour paid)
• Substantial public transportation discounts (Tri-met and C-Tran)
• Tuition Reimbursement
• Innovative Employee Assistance Program (EAP) including extensive wellness resources

Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or aaeo@ohsu.edu.