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 nurse in this position will provide comprehensive review of patient records in a remote setting.  The Registered Nurse provides complex case review, queries clinicians for clarification of unclear diagnoses.

 

• Facilitates appropriate clinical documentation to support appropriate diagnosis coding and to ensure the level of service rendered to all patients is recorded.
• Collaborates with inpatient coding staff to promote complete and accurate clinical documentation.
• Communicates with licensed providers, case managers, coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making and medical documentation. 
• Assigns a working DRG, Vizient Variables and severity level using coding rules and guidelines.
• Analyze clinical information to identify areas within the chart for potential gaps in provider documentation.
• Queries providers to clarify documentation in the medical record.
• Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).
• Conducts post discharge reviews for comparative analysis of CDI Specialist and inpatient coding DRG, Vizient variables and severity level assignment. Escalates clinical issues to CDI and Coding leadership.
• Develops and conducts ongoing education for new staff, including new CDI specialists, physicians and nursing as needed.
• Utilizes software systems (including encoder) to collect, track, and report outcomes. Requires proficiency in abstracting and data entry into all databases used for clinical documentation.  Maintains integrity of data collection.
• Participates in ongoing educational meetings with staff.  Collaborates with team to improve workflow and tools relative to documentation improvement practices for individual practitioners and groups of clinicians including handouts, PowerPoint, etc...

• Minimum 2 years of Clinical Documentation Integrity experience
• Certified Clinical Documentation Specialist (CCDS or CDIP) certification within 6 months of hire
• Current, unencumbered Oregon State Registered Nurse License
• Associate's or Baccalaureate Degree in Nursing from a program accredited by Commission of Collegiate Nursing Education (CCNE), Accreditation Commission for Education in Nursing (ACEN) or Commission for Nursing Education Accreditation (CNEA) 
• Associate degree Nurses required to enroll in BSN program within 3 years of hire and complete within 5 years of hire
• Must be able to perform the essential functions of the position with or without accommodation

• This position also comes with great benefits! Some highlights include:

  • Comprehensive health care plans. Covered 100% for full-time employees and 88% for dependents.
  • $50K 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
    • Holidays - up to 64 holiday hours per calendar year (employees accrue .0308 holiday hours for each hour paid – included in vacation accruals)
  • Sick Leave - 96 hours per year, prorated for part-time
  • Substantial public transportation discounts (Tri-met and C-Tran)
  • Tuition Reimbursement
  • Innovative Employee Assistance Program (EAP) including extensive wellness resources

1 position available

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.