What are the responsibilities and job description for the Clinical Documentation Spec position at Loma Linda University Health?
Job Description
MC: Clinical Documentation Imp- (Full Time, Days) -
Job Summary: The Clinical Documentation Specialist is responsible for concurrent clinical documentation review with an emphasis on completeness and accuracy of provider documentation related to intensity of service required and severity of illness upon hospitalization and throughout patient stay. Initiates communication, verbal and written, with providers to facilitate clarification of need for greater specialty or completeness of the medical record. Provides formal education related to documentation integrity and completeness at medical staff department meetings and committees. Keeps physician leaders in areas of responsibility informed of pertinent data, documentation trends, and opportunities for learning and improvement related to documentation integrity. Performs other duties as needed.
Education and Experience: Bachelor's Degree in Nursing from an accredited school or Bachelor's Degree in Health Information Management (HIM) required. Bachelor's Degree in Nursing in progress acceptable with quarterly updates provided. Minimum three years of acute hospital nursing or acute hospital coding experience required. For nurses filling role one year of recent (within one year) acute care nursing experience required. Critical Care or ED experience preferred. For CDS members practicing in pediatric areas, minimum three years of pediatric acute hospital nursing experience required, PICU or NICU preferred.
Knowledge and Skills: Recent experience as acute hospital utilization reviewer or Case Manager with knowledge of third party reimbursement requirements preferred. Able to read; write legibly; speak in English with professional quality; use computer and software programs necessary to the position; troubleshoot and calibrate patient care equipment. Able to relate and communicate positively, effectively, and professionally with others; be assertive and consistent in following or enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, and collaborate; accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; work independently with minimal supervision; performs basic math functions; manage multiple assignments effectively; work well under pressure; problem solve; organize and prioritize workload; recall information with accuracy; pay close attention to detail. Able to distinguish colors and smells as necessary for patient care; hear sufficiently for general conversation in person and on the telephone; identify and distinguish various sounds associated with the work place or patient care; see adequately to read computer screens, medical records, and written documents necessary to position; discern temperature variances through touch.
Licensures and Certifications: California Registered Nurse (RN) License required for nurse filling role.
About Us
Our mission is to continue the teaching and healing ministry of Jesus Christ. Our core values are compassion, excellence, humility, integrity, justice, teamwork and wholeness.
About The Team
Loma Linda University Health is a Seventh-day Adventist, faith and values based Christian institution. Candidates must understand and embrace the mission, purpose, and identity of Loma Linda and its affiliated entities.
We are an equal opportunity employer committed to the principles of diversity. We provide equal opportunities in all aspects of the employment process to every individual, regardless of gender, race, color, age, national origin, ancestry, physical or mental disability, marital or veteran status, genetic information or any other characteristic protected by law. In addition, we will provide reasonable accommodations for otherwise qualified individuals requesting an accommodation due to a disability. If you need accommodation assistance with accessing our job listings or completing an application, or during any other phase of employment with us, please contact Human Resources Management at (909) 651-4001.
Loma Linda University Medical Center is a religiously-qualified Equal Opportunity Employer under Title VII of Civil Rights Act of 1964. No question on this application is asked for the purpose of unlawfully limiting or excluding any applicant’s consideration for employment because of race, color, religion, gender, age, national origin, disability, genetic information, or any other status protected by applicable law. If you need a reasonable accommodation in the hiring process, please notify Human Resource Management.
We appreciate your interest in Loma Linda and wish you success in your job search!
MC: Clinical Documentation Imp- (Full Time, Days) -
Job Summary: The Clinical Documentation Specialist is responsible for concurrent clinical documentation review with an emphasis on completeness and accuracy of provider documentation related to intensity of service required and severity of illness upon hospitalization and throughout patient stay. Initiates communication, verbal and written, with providers to facilitate clarification of need for greater specialty or completeness of the medical record. Provides formal education related to documentation integrity and completeness at medical staff department meetings and committees. Keeps physician leaders in areas of responsibility informed of pertinent data, documentation trends, and opportunities for learning and improvement related to documentation integrity. Performs other duties as needed.
Education and Experience: Bachelor's Degree in Nursing from an accredited school or Bachelor's Degree in Health Information Management (HIM) required. Bachelor's Degree in Nursing in progress acceptable with quarterly updates provided. Minimum three years of acute hospital nursing or acute hospital coding experience required. For nurses filling role one year of recent (within one year) acute care nursing experience required. Critical Care or ED experience preferred. For CDS members practicing in pediatric areas, minimum three years of pediatric acute hospital nursing experience required, PICU or NICU preferred.
Knowledge and Skills: Recent experience as acute hospital utilization reviewer or Case Manager with knowledge of third party reimbursement requirements preferred. Able to read; write legibly; speak in English with professional quality; use computer and software programs necessary to the position; troubleshoot and calibrate patient care equipment. Able to relate and communicate positively, effectively, and professionally with others; be assertive and consistent in following or enforcing policies; work calmly and respond courteously when under pressure; lead, supervise, teach, and collaborate; accept direction. Able to communicate effectively in English in person, in writing, and on the telephone; think critically; work independently with minimal supervision; performs basic math functions; manage multiple assignments effectively; work well under pressure; problem solve; organize and prioritize workload; recall information with accuracy; pay close attention to detail. Able to distinguish colors and smells as necessary for patient care; hear sufficiently for general conversation in person and on the telephone; identify and distinguish various sounds associated with the work place or patient care; see adequately to read computer screens, medical records, and written documents necessary to position; discern temperature variances through touch.
Licensures and Certifications: California Registered Nurse (RN) License required for nurse filling role.
About Us
Our mission is to continue the teaching and healing ministry of Jesus Christ. Our core values are compassion, excellence, humility, integrity, justice, teamwork and wholeness.
About The Team
Loma Linda University Health is a Seventh-day Adventist, faith and values based Christian institution. Candidates must understand and embrace the mission, purpose, and identity of Loma Linda and its affiliated entities.
We are an equal opportunity employer committed to the principles of diversity. We provide equal opportunities in all aspects of the employment process to every individual, regardless of gender, race, color, age, national origin, ancestry, physical or mental disability, marital or veteran status, genetic information or any other characteristic protected by law. In addition, we will provide reasonable accommodations for otherwise qualified individuals requesting an accommodation due to a disability. If you need accommodation assistance with accessing our job listings or completing an application, or during any other phase of employment with us, please contact Human Resources Management at (909) 651-4001.
Loma Linda University Medical Center is a religiously-qualified Equal Opportunity Employer under Title VII of Civil Rights Act of 1964. No question on this application is asked for the purpose of unlawfully limiting or excluding any applicant’s consideration for employment because of race, color, religion, gender, age, national origin, disability, genetic information, or any other status protected by applicable law. If you need a reasonable accommodation in the hiring process, please notify Human Resource Management.
We appreciate your interest in Loma Linda and wish you success in your job search!