Clinical Documentation Specialist, Clinician

Sutter Health System Office-Valley

Conducts concurrent and retrospective reviews of patient medical records to evaluate the accuracy and completeness of clinical documentation, ensuring notes reflect the severity of patient's illness and quality of care. Interacts thoughtfully and effectively with physicians, patient care team, and ancillary departments to gather and clarify medical record documentation. Identifies opportunities for improvement to ensure understanding of documentation requirements, optimize reimbursement for the level of service rendered, and enhance the measurement and reporting of outcomes.

Education: Graduate of an accredited school of nursing OR Foreign trained physician

Certification & Licensure: RN-Registered Nurse of California OR Foreign trained physician

CDIP or CCDS strongly preferred

Typical Experience: 5 years recent relevant experience.

Skills and Knowledge: Clinical knowledge of diagnoses, severity of illness, risk of mortality, co-morbidities and complications. Knowledge of age-specific needs and the elements of disease processes and related procedures. Knowledge of current coding classification and reimbursement guidelines and regulations. Critical thinking with the ability to analyze and interpret medical record/clinical documentation and formulate appropriate physician queries. Ability to define issues, collect data, establish facts and draw valid conclusions. Demonstrates a proactive approach in identifying and addressing issues and concerns. Collaboration skills to facilitate open sharing of information and cooperation with various stakeholders to problem solve and achieve desired results/outcome. Displays a customer service focus in all decisions and actions. Ability to communicate through verbal and written means, and to present information to a variety of audiences. Ability to create and translate data into reports and presentations for appropriate audience. Organization skills to effectively manage and/or re-prioritize activities and projects to meet deadlines while maintaining a high degree of responsiveness. Ability to interact and maintain effective working relationships with those contacted in the performance of required duties. Demonstrates respect for cultural and linguistic differences and promotes an inclusive work environment. Demonstrates initiative in providing feedback/input to improve workflow/processes. Ability to work effectively in a dynamic and fast-paced environment with changing business priorities. Ability to maintain and work discreetly with confidential information. Ability to use essential applications and/or databases associated with the role's duties and responsibilities.

Job Shift: Days

Schedule: Full Time

Shift Hours: 8

Days of the Week: Monday - Friday

Weekend Requirements: None

Benefits: Yes

Unions: No

Position Status: Non-Exempt

Weekly Hours: 40

Employee Status: Regular

Pay Range is $82.86 to $108.54 / hour

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.