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RN - Clinical Documentation Integrity Specialist (Float) Job

PeaceHealth Southwest Medical Center
Type Full time Posted 12/3/2013
Salary - n/a - Starts 4/15/2014
WA - Washington (All) - Vancouver Referral - n/a -    

RN - Clinical Documentation Integrity Specialist (Float) Job

Date:Mar 22, 2014

LocationVancouver, WA, US


Req ID:17721

At PeaceHealth, we carry on the healing mission of Jesus Christ by promoting personal and community health, relieving pain and suffering, and treating each person in a loving and caring way. The fulfillment of this Mission is our shared purpose. It drives all that we are and all that we do. To those who embrace the spirit of these words and our commitment to Exceptional Medicine and Compassionate Care, we offer the opportunity to learn and grow as a member of the PeaceHealth family.

Department:Health Info Mgmt System (9210)


Responsible for improving the overall quality and completeness of clinical documentation. Facilitates modifications to clinical documentation through extensive interaction with key stakeholders to ensure that appropriate reimbursement is received for the service rendered. Ensures the accuracy and completeness of clinical information used for measuring and reporting outcomes. Educates all members of the patient care team on an ongoing basis.


Performs review of clinical documentation to include: review of admission/continued stays using best practices to facilitate obtaining and incorporating modifications from key stakeholders. Ensures the overall accuracy, completeness and timeliness of the clinical documentation to support the coding process in attaining the appropriate Diagnosis Related Groups (DRG).

Ensures the completeness and accuracy of the clinical documentation by: formulating credible clarification, conferring with providers to clarify clinical diagnosis terminology and obtain needed documentation,

Provides training to providers and caregivers to facilitate accuracy of clinical documentation, impact on coding and reimbursement and to improve methodologies for capturing correct information.

Ensures the completeness and accuracy of the clinical documentation by: processing discharges to update the DRG worksheet to reflect changes in status, procedures/treatments and conferring with provider to finalize diagnoses.

Reviews clinical documentation for issues, identifies trends with incomplete or inaccurate information and clinical issues . Works with key stakeholders in a timely manner to ensure points of clarification are recorded in patient charts, accurate DRG assignment and issues resolved for coding and reimbursement.

Acts as a resource for best practices in clinical documentation, impact of Medicare guidelines and facilitates educating key stakeholders on changes.

Participates as a member of the CDMP® Task Force.

Performs other related duties as may be assigned.



Graduate of an accredited school/college of nursing; Bachelors degree in Nursing, Healthcare Administration or equivalent healthcare degree is preferred.


Minimum 3 years acute care nursing experience in hospital setting, preferably Critical Care or Medical /Surgical, or equivalent education and/or experience may be considered, as evidenced by sound critical thinking skills, ability to collaborate and communicate effectively with interdisciplinary care teams and leadership.
Experience as a Compliance Documentation Specialist in a hospital program is preferred.
Prefer experience with JA Thomas software.
Knowledge of Diagnosis Related Groups is preferred.


Current Registered Nurse licensure in the state in which nurse will be practicing.

CCDS (Certified Clinical Documentation Specialist) preferred.
CCRN (Critical Care Registered Nurse) certification preferred

Other Skills:

Strong verbal, written and interpersonal communication skills are required.
Ability to interact effectively with providers and all levels of staff to achieve quality outcomes is required.
Ability to effectively communicate clinical information is required.
Ability to analyze/problem solve is required.
Computer skills to include word processing, spreadsheet and data entry are required.
Strong organization skills with the ability to work in a fast-paced environment independently and as part of an interdisciplinary team are required.
Good critical thinking skills, able to assess, evaluate and teach are required.
Working knowledge of all areas of adult medicine is required.

Location:  Vancouver, WA 
Job Category:  IT/Health Information Management; Nursing - RN Other; Nursing - RN Patient Care
Shift:  Day
Shift Length:8 Hours
Work Type:  Full Time
Salary range starts at:$33.84
Required Certifications/Licensure: 

The above information on this description has been designed to indicate the general nature and level of work performed within this job class. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of caregivers assigned to this job.

Posting Notes: Vancouver, WA || IT/Health Information Management; Nursing - RN Other; Nursing - RN Patient Care || Full Time || HEALTH INFO MGMT 

Nearest Major Market:Portland Oregon
Nearest Secondary Market:Tacoma
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