What are the responsibilities and job description for the Clinical Documentation Specialist position at San Bernardino County?
The Job
Arrowhead Regional Medical Center (ARMC) is looking for Clinical Documentation Specialists* to perform chart review, analyze documentation, clinical conditions, and treatments required for an accurate representation of severity of illness. This position is responsible for identifying the expected risk of mortality and complexity of care for a patient's medical record in support of quality patient care and a healthy revenue cycle.
Clinical Documentation Improvement (CDI) is the process of reviewing medical record documentation for completeness, specifics, and accuracy, reviewing disease process, diagnostic findings, and what the documentation might be missing. A Clinical Documentation Specialist* manages, assesses, and reviews a patient’s medical records to ensure that all the information documented reflects the patient’s severity of illness, clinical treatment, and the accuracy of documentation. Part of the role is to perform concurrent reviews of medical records, validate diagnosis codes, identify missing diagnosis, and query physicians and other healthcare providers for more specifics so documentation accurately reflects the patient’s severity of illness. In addition, Clinical Documentation Specialists* educate physicians on the importance of supplying the proper information needed for correct documentation.
Located on a beautiful 70-acre campus in Colton, California (50 miles east of Los Angeles), Arrowhead Regional Medical Center (ARMC) is a state-of-the-art, public/nonprofit, 456-bed, university affiliated teaching hospital licensed by the State of California Department of Public Health and accredited by The Joint Commission. The hospital houses a regional burn center serving four counties (San Bernardino, Riverside, Mono and Inyo), a comprehensive stroke center, level I trauma center and a freestanding in-patient behavioral health center. Additionally, ARMC operates five community-based, primary care clinics and over 40 specialty care outpatient services. ARMC is the primary teaching hospital for the adjacently located California University of Science and Medicine (CUSM), the Inland Empire's newest medical school.
CONDITIONS OF EMPLOYMENT
Pre-Employment Process: Applicants selected for these positions must pass a background investigation, physical, and verification of employment history and education.
Travel: Travel throughout the County may be required. A valid California Class C driver license is required at time of appointment.
Sponsorship: Please note San Bernardino County is not able to consider candidates who will require visa sponsorship at the time of application or in the future.
Minimum Requirements
Candidates must meet all of the following:
License:
Must possess and maintain Registered Nurse licensure with the State of California Board of Registered Nursing.
Certification: Must possess and maintain current Healthcare Provider level Basic Life Support (BLS) certification.
Experience:
The ideal candidate will have a Bachelor's degree in Nursing with at least five (5) years of experience working in acute care as a Case Manager or similar related experience. One (1) year of CDI experience is preferred.
Selection Process
Application Procedure: Applications will be accepted until a sufficient number of qualified applications are received. To receive priority consideration for this excellent opportunity, please complete and submit the online employment application and supplemental questionnaire as soon as possible. Resumes will not be accepted in lieu of the application and/or supplemental questionnaire.
There will be a competitive evaluation of qualifications based on the information provided in your Application and the Supplemental Questionnaire. The most highly qualified candidates, based on the evaluation results, will be referred for an interview. Be sure to include in your application and supplemental questions your experience in meeting the minimum requirements.
To ensure timely and successful submission of your online application, please allow ample time to complete and submit your application before the posted filing deadline. Applicants will be automatically logged-out if they have not submitted the application and all required materials prior to the posted deadline. Once your application has been successfully submitted you will receive an onscreen confirmation and an email. We recommend that you save and/or print these for your records. Please note, if you do not receive an onscreen confirmation and an email acknowledging our receipt of your application we have not received your application.
If you require technical assistance, please click HERE to review the Government Jobs online application guide , or contact their Toll-Free Applicant Support line at (855) 524-5627. Please note that Human Resources is not responsible for any issues or delays caused by the internet connection, computer or browser used to submit the application.
EEO/ADA: San Bernardino County is an Equal Employment Opportunity (EEO) and Americans with Disabilities Act (ADA) compliant employer, committed to providing equal employment opportunity to all employees and applicants.
ADA Accommodation: If you have a disability and require accommodations in the testing process, submit the Special Testing Accommodations Request Form within one week of a recruitment filing deadline.
Veterans’ Preference: Eligible veterans and their spouse or widow(er) who are not current County employees may be awarded additional Veterans’ Preference points. Click HERE for information and instructions to request Veteran's Preference points.
Please click HERE for important Applicant Information and the County Employment Process
Arrowhead Regional Medical Center (ARMC) is looking for Clinical Documentation Specialists* to perform chart review, analyze documentation, clinical conditions, and treatments required for an accurate representation of severity of illness. This position is responsible for identifying the expected risk of mortality and complexity of care for a patient's medical record in support of quality patient care and a healthy revenue cycle.
Clinical Documentation Improvement (CDI) is the process of reviewing medical record documentation for completeness, specifics, and accuracy, reviewing disease process, diagnostic findings, and what the documentation might be missing. A Clinical Documentation Specialist* manages, assesses, and reviews a patient’s medical records to ensure that all the information documented reflects the patient’s severity of illness, clinical treatment, and the accuracy of documentation. Part of the role is to perform concurrent reviews of medical records, validate diagnosis codes, identify missing diagnosis, and query physicians and other healthcare providers for more specifics so documentation accurately reflects the patient’s severity of illness. In addition, Clinical Documentation Specialists* educate physicians on the importance of supplying the proper information needed for correct documentation.
- Official Job Title: Clinical Documentation Improvement Nurse. For more detailed information, refer to the Clinical Documentation Improvement Nurse job description.
Located on a beautiful 70-acre campus in Colton, California (50 miles east of Los Angeles), Arrowhead Regional Medical Center (ARMC) is a state-of-the-art, public/nonprofit, 456-bed, university affiliated teaching hospital licensed by the State of California Department of Public Health and accredited by The Joint Commission. The hospital houses a regional burn center serving four counties (San Bernardino, Riverside, Mono and Inyo), a comprehensive stroke center, level I trauma center and a freestanding in-patient behavioral health center. Additionally, ARMC operates five community-based, primary care clinics and over 40 specialty care outpatient services. ARMC is the primary teaching hospital for the adjacently located California University of Science and Medicine (CUSM), the Inland Empire's newest medical school.
CONDITIONS OF EMPLOYMENT
Pre-Employment Process: Applicants selected for these positions must pass a background investigation, physical, and verification of employment history and education.
Travel: Travel throughout the County may be required. A valid California Class C driver license is required at time of appointment.
Sponsorship: Please note San Bernardino County is not able to consider candidates who will require visa sponsorship at the time of application or in the future.
Minimum Requirements
Candidates must meet all of the following:
License:
Must possess and maintain Registered Nurse licensure with the State of California Board of Registered Nursing.
Certification: Must possess and maintain current Healthcare Provider level Basic Life Support (BLS) certification.
Experience:
- Option 1: Three (3) years of Medical-Surgical Registered Nurse experience in an acute care hospital.
- Option 2: Two (2) years of experience as a Registered Nurse in Case Management or Managed Care.
The ideal candidate will have a Bachelor's degree in Nursing with at least five (5) years of experience working in acute care as a Case Manager or similar related experience. One (1) year of CDI experience is preferred.
Selection Process
Application Procedure: Applications will be accepted until a sufficient number of qualified applications are received. To receive priority consideration for this excellent opportunity, please complete and submit the online employment application and supplemental questionnaire as soon as possible. Resumes will not be accepted in lieu of the application and/or supplemental questionnaire.
There will be a competitive evaluation of qualifications based on the information provided in your Application and the Supplemental Questionnaire. The most highly qualified candidates, based on the evaluation results, will be referred for an interview. Be sure to include in your application and supplemental questions your experience in meeting the minimum requirements.
To ensure timely and successful submission of your online application, please allow ample time to complete and submit your application before the posted filing deadline. Applicants will be automatically logged-out if they have not submitted the application and all required materials prior to the posted deadline. Once your application has been successfully submitted you will receive an onscreen confirmation and an email. We recommend that you save and/or print these for your records. Please note, if you do not receive an onscreen confirmation and an email acknowledging our receipt of your application we have not received your application.
If you require technical assistance, please click HERE to review the Government Jobs online application guide , or contact their Toll-Free Applicant Support line at (855) 524-5627. Please note that Human Resources is not responsible for any issues or delays caused by the internet connection, computer or browser used to submit the application.
EEO/ADA: San Bernardino County is an Equal Employment Opportunity (EEO) and Americans with Disabilities Act (ADA) compliant employer, committed to providing equal employment opportunity to all employees and applicants.
ADA Accommodation: If you have a disability and require accommodations in the testing process, submit the Special Testing Accommodations Request Form within one week of a recruitment filing deadline.
Veterans’ Preference: Eligible veterans and their spouse or widow(er) who are not current County employees may be awarded additional Veterans’ Preference points. Click HERE for information and instructions to request Veteran's Preference points.
Please click HERE for important Applicant Information and the County Employment Process
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