Clinical Documentation Specialist- Family Maternity Center (40 hrs/wk, Day)
Company: Evergreen Healthcare
Posted on: June 8, 2021
The Clinical Documentation Specialist for our Family Maternity
Center (FMC) specializes in ensuring that the documentation in the
patient health record reflects the clinical acuity of the patient.
Works in partnership with physicians to ensure clinical information
in medical record is present and accurate; and with the Medical
Center Coding Staff to support that appropriate clinical severity
is captured for the level of service rendered to all patients
within a DRG-based payor system.
Reviews Family Maternity Center OB ED and inpatient admissions,
as well as newborn and Neonatal Intensive Care Unit (NICU)
admissions to identify and improve clinical documentation in the
medical record to reflect appropriate severity of illness, risk
factors and quality of care provided. Uses a worksheet format to
document reviews in order to facilitate reporting and process
Communicates with physicians and coders to ensure accurate and
complete documentation in the medical record that reflects the
clinical condition of the patient in language that can be coded
Performs other duties as assigned.
License, Certification, Education or Experience:
REQUIRED for the position: Current State of Washington RN
license, Bachelors of Science degree in Nursing, 5 years of
experience as an RN with a minimum of three years of obstetric,
postpartum, emergency department or NICU experience. Current
Healthcare Provider BLS certification by date of hire, Training in
clinical documentation at time of hire or must obtain within three
months of hire. Ability to assess, plan, implement and evaluate
patient care. Knowledge of the healthcare financial environment,
reimbursement and levels of care. Strong verbal and written
communication skills Demonstrated ability to work with
multidisciplinary teams, and to provide feedback related to
clinical documentation to nursing and provider teams.
DESIRED for the position: CCDS certification
To learn more about our Family Maternity Center, please click
Keywords: Evergreen Healthcare, Kirkland , Clinical Documentation Specialist- Family Maternity Center (40 hrs/wk, Day), Other , Kirkland, Washington
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