Clinical Documentation Specialist - HID
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Education Requirements:
Bachelor's Degree in Nursing or Health Information Management; Foreign medical degree may be considered;
License/Certification/Registration Requirements:
Current RN license (not limited to State of California) or higher clinical degree (i.e. MD), or Registered Health Info Admin. (RHIA), or Registered Health Info Tech. (RHIT) or Certified Clinical Documentation Specialist.
Experience:
- Minimum of 3 years Acute Care experience in Clinical Care, Utilization Review, Coding, or Case Management. Working knowledge of TJC standards and regulatory requirements.
- A high level of clinical knowledge required to participate collaboratively with all members of the care team.
- Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes
- Strong critical thinking skills and exceptional ability to integrate knowledge
- Excellent observation, communication and decision making abilities
- Strong ability to assess, analyze, and evaluate data
- Intermediate to advanced organizational and computer skills required
- Ability to prioritize work, clearly communicate, interact with, and teach all levels of professions, including but not limited to physicians and nursing personnel, managers, various support staff departments, physician offices, and coding.
- The department will consider training an Internal applicant with strong Critical Care, PACU or ED experience.
Physical Demands:
- Ability to sit or stand for prolonged periods of time in conjunction with assignments (up to 95% of scheduled work shift)
- Ability to walk for extended periods of time (from 35%-65% of the scheduled work shift)
- Bending, stooping, turning or reaching with arms (less than 35% of the scheduled work shift)
- Lifts, carries, moves and pushes/pulls equipment (laptop computer, rolling bag, books, and paperwork) and materials related to assigned work demanding ability to lift up to 30 pounds.
- Ability to use a computer keyboard, perform data entry, and look at a computer monitor for extended periods of time.
- Talking, seeing, hearing required for more than 65% of the time
- May include travel by shuttle or car for offsite work locations