Providence RN Clinical Documentation Specialist in Oregon City, Oregon
Providence is calling an RN Clinical Documentation Specialist to the CDI Department located at Providence Willamette Falls Medical Center in Oregon City, OR
(1.0 FTE, Monday- Friday Days)
We are seeking a Registered Nurse Clinical Documentation Specialist that will be part of a regional team that facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. This requires analysis of clinical information to identify areas within the medical record for potential gaps in physician documentation.
This position assists with necessary modification to clinical documentation through extensive interaction with physicians. It requires work with coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care.
This position develops and implements plans for education of physicians, nursing and ancillary staff on documentation improvement.
In this position you will have the following responsibilities:
Apply concepts of the nursing process, such as identification of disease, facilitation of healing, health promotion, illness prevention and patient care delivery to each task, clinical review and or quality improvement project
Be responsible for improving the overall quality and completeness of clinical documentation by performing medical record documentation review for the Oregon Region
On a daily basis reviews 100% of patient medical records, searching medical entries for appropriate documentation
Use clinical knowledge to collaborate with providers in identifying appropriateness of clinical documentation; identifying potential diagnoses vs. symptomology.
Champion and assist providers in choosing correct terminology in medical record documentation for patients' illnesses and disease processes
Work with Health Information Management coding staff to more accurately reflect case mix indices by improving documentation during the patients' stay, which is reflected in the subsequent coding that occurs post discharge
Participate in work group and steering committees to facilitate improved processes in concurrent coding
Demonstrate understanding and utilizes tools, tones and behaviors that promote patient safety in a highly reliable organization
Use expert clinical knowledge in pathophysiology and disease processes on a daily basis to support the requests for changes in documentation that are reviewed
Use clinical knowledge to apply Diagnosis Related Group methodology as means for improving revenue capture
Serve as resource and role model in specialty areas
Required qualifications for this position includes:
Bachelor's Degree in Nursing -OR- A MD graduate (educated in foreign country or US) may also be accepted in lieu of a BA in Nursing
Current, unencumbered Oregon state RN license
Five (5) years of Recent acute care experience in adult acute, critical care, or strong medical/surgical setting
Demonstrated clinical experience related to a wide variety of patient populations and care delivery models
Demonstrated experience in communicating effectively, both verbally and in writing, with physicians, nursing, public, and all levels of hospital management
Preferred qualifications for this position include:
- Master's Degree in Nursing
About Providence in Oregon
As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.
The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple,
"Providence will provide the best care and service to every person, every time."
Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.
For information on our comprehensive range of benefits, visit:
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Case Management
Location: Oregon-Oregon City
Req ID: 281515