To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
The Clinical Documentation Specialist I RN will facilitate modifications to clinical documentation, through extensive concurrent interactions with physicians and other clinicians in order to reflect appropriate clinical severity, complications and co-morbidity. The specialist shall concurrently review and evaluate selected patient's medical records for overall quality and completeness. Will educate physicians, non-physician clinicians, nurses and coding staff on an ongoing basis regarding documentation opportunities, coding and reimbursement issues and relevant quality and performance improvement opportunities. Will identify quality of care issues in documentation and will seek resolution of issue through appropriate channels.
Registered Nurse with active license, BSN preferred. CCS preferred.
At least three (3) years of recent acute care nursing experience required. ICU experience preferred. Clinical expertise required.
RN license required. CCS preferred.
Excellent communication, negotiation and organizational skills. Adaptability to a wide variety of interpersonal encounters with the entire hospital team. Comprehensive understanding in use of medical record to extract data. Working knowledge of third party and prospective payment systems. Computer PC literacy required. Must be able to work collaboratively and independently. Must be flexible with responsibilities in order to meet departmental needs. Must have keen eye to detail.
Ability to communicate clearly and confidently to providers the program goals and documentation issues using email, in person communication, telephone and other written and electronic forms of communication.