Clinical Docum Improvement Spclst
PeaceHealth - Springfield, OR

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This position will travel between PeaceHealth locations.

Responsible for facilitating the improvement of the overall quality and completeness of clinical documentation in the patient record through extensive interaction with physicians, nursing staff, other patient caregivers, and HIM coding staff. The CDS role is to ensure that the medical record documentation provides an accurate representation of the patient's clinical care, diagnosis, and severity.


Improve the overall quality and completeness of clinical documentation by performing accurate and timely record reviews, admission/continued stay reviews using Compliant Documentation Program Management guidelines. Recognize opportunities for documentation improvement.

Actively participate in team meetings and education of staff. Follow chain of command for intradepartmental issues. Communicate with HIM staff to resolve discrepancies.

Educate and communicate on compliant documentation opportunities and reimbursement issues, as well as performance improvement methodologies on an ongoing basis. Effective and appropriate communication with physicians.

Conduct follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart. Formulate clinically credible clarifications.

Review clinical issues with coding staff to assign a working DRG as needed.

Assist with management of CDMPTrak as needed.

Serve as a member of the CDMP Task Force.

Demonstrate knowledge of DRG payor issues, documentation opportunities, clinical documentation requirements, general coding guidelines, and referral policies and procedures.

Facilitate modifications to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients with a DRG based payor, and to ensure the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes.

Assist with special projects as needed.

Perform other duties as assigned.


Graduate of an accredited state board of nursing program. BSN is preferred. WA State: May be education for a RN or LPN.

Three years recent clinical experience in a hospital setting, preferable ICU or Med/Surg or three years experience as a compliance documentation improvement specialist in a hospital program.

Current Washington state RN license preferred or LPN license with CCDS (Certified Clinical Documentation Specialist) required.

Current State of Oregon registered nurse license.

BSN and CCDS preferred.

Excellent observation, analytical thinking, and problem solving skills.

Excellent verbal and written communication skills.

Ability to learn/develop skills necessary to perform CDMP.

Dependable and self-directed, able to work independently.

Demonstrate ethical conduct.

Good critical thinking skills, able to access, evaluate and teach. Flexible with a working knowledge of all areas of adult medicine.

Knowledge of pathophysiology and disease process.

Good computer skills. Familiarity with windows based software programs.

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. Employees of PeaceHealth embrace the spirit of these words and share our commitment to Exceptional Medicine and Compassionate Care, and are willing to learn and grow as a member of the PeaceHealth family.

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 employees assigned to this job.

About this company
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PeaceHealth, based in Vancouver, Washington, is a not-for-profit Catholic health system offering care to communities in Washington, Oregon,...