**We are looking for a Clinical Documentation Specialist RN II for the Health Information Services Department at Santa Rosa Memorial Hospital. Apply Today! Applicants that meet qualifications will receive a text with some additional questions from our Modern Hire system.**Location: Santa Rosa, CAWork Schedule: Full Time – 80 Biweekly HoursShift: 8-hour, Days**Job Summary:**Responsible for facilitating the improvement in the overall quality and completeness of medical record documentation. Obtains appropriate clinical documentation throughout extensive interaction with physicians, nursing staff, other patient care givers, and Information Service Clinical Coders to ensure that appropriate reimbursement is received for the level of services rendered to patients. The Clinical Documentation Specialist ensures the clinical information utilized in profiling and reporting outcomes is complete and accurate. On an ongoing basis is responsible for the education of the Case Management staff and all members of the patient care team on documentation guidelines.**Essential Functions:**+ Facilitates appropriate clinical documentation to ensure that level of services and acuity of care are accurately reflected in the medical record.+ Demonstrates knowledge of documentation requirements and guidelines in accordance with Coding Clinic. Reviews clinical issues with coding staff to assign a working DRG.+ Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines.+ Processes discharges by updating the MEDITECH CDMP screens to reflect any changes in status, procedures/treatments and conferring with physician to finalize diagnosis.+ Conducts follow-up reviews of clinical documentation to ensure points of clarification with the physician have been recorded in the patient s chart. Tracks responses to CDMP and trends in compliance.+ Maintains positive open communication with physicians, interdisciplinary care team members and department manager.+ Serves as a member of the CDMP Task Force and participates in the scheduled meetings.**Skills:**+ Knowledge of physical and psychological characteristics of illness and medical terminology.+ Knowledge of age related developmental stages and needs.+ Demonstrates clinical knowledge skills/abilities for the patient population served.+ Ability to work collaboratively on a team.+ Excellent interpersonal, verbal and written communication skills.+ Ability to work independently and make decisions.+ Excellent organizational skills.+ Ability to work effectively under pressure due to changing priorities, interruptions, high and low census, payor demands and discharge planning demands.+ Ability to demonstrate leadership skills in facilitating constructive change.+ Computer knowledge.**Minimum Position Requirements:****Experience:** Case Management or acute care experience in a healthcare setting.**Licenses/Certifications:**+ Current Registration with the California Board of Registered Nursing.+ California RN Nursing license.+ CPR.**Preferred Position Qualifications:****Education:** Bachelor’s Degree**Experience:** Managed care experience.**Licenses/Certifications:** Certified Case Manager.Providence St. Joseph Health (Providence) has worked for decades to improve health and quality of life in California’s North Bay region, starting in Sonoma County, where the Sisters of St. Joseph of Orange opened the doors of Santa Rosa Memorial Hospital in 1950. Today, we continue the mission begun by the Sisters to those we serve through an integrated spectrum of primary, urgent, acute, outpatient, palliative care and regional referral services. Sonoma County facilities aligned with Providence include the 278-bed Santa Rosa Memorial Hospital, the region’s only Level II trauma center. In addition, the 80-bed Petaluma Valley Hospital and 43-bed Healdsburg Hospital are secular (non-religious) affiliates of Providence. Our services also encompass three Urgent Care centers, Hospice of Petaluma, Memorial Hospice and North County Hospice, the Annadel Medical Group doing business as St. Joseph Health Medical Group, as well as the St. Joseph Home Care Network (post-acute care services). We act as a regional referral hub for outlying hospitals, while also providing outpatient behavioral health care, education to promote health and prevent chronic disease, rehabilitation, oral health care, community benefit programs, and more, all fostering health and quality of life throughout the area.Providence provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Providence complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.Positions specified as “on call/per diem” refers to employment consisting of shifts scheduled on as “as needed basis” to fill in for staff vacancies.Company: Sonoma County EntitiesCategory: Quality NursingReq ID: R340934
Associated topics: cardiothoracic, care unit, intensive care, neonatal, nurse clinical, nurse rn, psychatric, psychiatric, staff nurse, surgical

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