Intermountain Healthcare Nurse Clinical Document Specialist - Full Time in St George, Utah
Greater St. George & Cedar City area
What does it mean to be a part of Intermountain Healthcare? It means that the quest for clinical excellence is not just a goal, but a given. It means building an environment where physicians and employees can deliver the best in healthcare. And it’s realizing each employee or volunteer is vital to the healing process, because we can only achieve theextraordinary together .
Being a part of Intermountain Healthcare means joining with a world-class team of over 36,000 employees and embarking on a career filled with opportunities, strength, innovation, and fulfillment. Our mission is: Helping people live the healthiest lives possible.
Our patients deserve the best in healthcare, and we deliver.
The CDS is responsible for reviewing inpatient medical records to facilitate the accurate representation of the severity of illness by improving the quality of physician clinical documentation. This involves extensive education, record review, and interaction with physicians, HIM professionals, and nursing staff. Active participation in team meetings and education of staff in the Clinical Documentation Management Program (CDMP) process is a key role of the CDS nurse.
Essential Job Duties
- Educates all members of the patient care team, including medical staff, on documentation guidelines on an ongoing basis. Orients new hires to CDMP processes.
- Reviews inpatient medical records for identified payer populations.
- Analyzes clinical status of patient, current treatment plan, and past medical history.
- Performs daily chart reviews to identify potential gaps in physician documentation.
- Formulates physicians' clarifications to ensure that clinical documentation reflects the severity of illness and level of service rendered to patient.
- Ensures current, accurate, and complete documentation of medical record.
- Conducts daily follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart.
- Clarifies clinical documentation through extensive interaction with physicians, nursing staff and other patient caregivers.
- Facilitate and plan monthly Task Force meeting for quality control of accuracy, completeness and timeliness of documentation; analyzes, interprets and reports findings of program impact to management.
- Acts as a resource and consultant to staff and physicians regarding clinical documentation.
- Benefits Eligible: Yes
- Shift Details: Full Time - 40 hours - Salaried Position
- Department: Clinical Documentation
- Bachelor's degree in Nursing (BSN) from an accredited institution (degree will be verified).
- RN license in state of Utah.
- 2 years clinical experience.
- Experience with pathophysiology and disease processes.
- Basic computer skills.
- Ongoing need for employee to see and read information, labels, monitors, identify equipment and supplies, and be able to assess patient needs.
- Frequent interactions with patient care providers, patients, and visitors that require employee to verbally communicate as well as hear and understand spoken information, alarms, needs, and issues quickly and accurately, particularly during emergency situations.
- Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use and typing for documenting patient care, accessing needed information, etc.
- Clinical experience in ICU, CCU, or intermediate care.
- Experience with Medicare Part A and B.
- Experience in CDMP documentation strategies.
All positions subject to close without notice. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.
Working Hours 40
Primary Work Location Dixie Reg River Road
Job Type Full Time
Location US-UT-St George