Clinical Documentation Specialist

Position: Clinical Documentation Specialist 3
Pay range: $98,488 - $147,742 annually, based on experience.
In addition, this role is eligible to work remotely from an approved state by St. Charles (please refer to the list). If you do not reside in an approved listed state (or do not plan to relocate to an approved listed state) we request, you do not apply for this particular position.
Approved states by St. Charles:
Oregon, Arizona, Arkansas, Florida, Idaho, Missouri, Montana, Nevada, New Mexico, North Carolina, Oklahoma, Tennessee, Utah, and Wisconsin.
About St. Charles Health System:
St. Charles Health System is a leading healthcare provider in Central Oregon, offering a comprehensive range of services to meet the needs of our community. We are committed to providing high-quality, compassionate care to all patients, regardless of their ability to pay. Our values of compassion, excellence, integrity, teamwork, and stewardship guide our work and shape our culture.

What We Offer:

Competitive Salary     Comprehensive benefits including Medical, Dental, Vision for you and your immediate family     403b with up to 6% match on Retirement Contributions     Generous Earned Time Off     Growth Opportunities within Healthcare
** ST. CHARLES HEALTH SYSTEM
**** JOB DESCRIPTION
***
* TITLE:

** Clinical Documentation Integrity Specialist III
** REPORTS TO POSITION:
** Manager, Clinical Documentation
** DEPARTMENT:
** Quality
* * DATE LAST REVIEWED:
** June 2023
** OUR VISION:
** Creating America’s healthiest community, together
** OUR MISSION:
** In the spirit of love and compassion, better health, better care, better value
** OUR VALUES:
** Accountability, Caring and Teamwork
*
* DEPARTMENT SUMMARY:

** The Clinical Documentation Department performs concurrent and selected retrospective medical record reviews in order to facilitate appropriate provider documentation that captures the most complete and accurate clinical conditions impacting patient visits.
*
* POSITION OVERVIEW:

** The
** Clinical Documentation Integrity Specialist 3
** rles Health System provides clinical based review and analysis of the documentation in the patient’s medical record to support accurate capture of patient’s complexity and severity of illness. Utilizes queries of the medical staff and other caregivers to clarify and support completeness of documentation.

This position does not directly manage any other Caregivers.
** ESSENTIAL FUNCTIONS AND DUTIES:
** Collaborates with physician, mid-level providers, ancillary staff, and medical records coders to identify principal and secondary diagnoses, and principal procedures. Also review for quality indicators.

Maintains current knowledge of Medicare’s rules, regulations, and guidelines.

Conducts initial and ongoing concurrent and some retrospective reviews for system wide admissions for all payors, initiates tracking process, and documents findings on EHR tracking system.

Identifies when there is a need to clarify documentation in patient records and initiates queries or communication with providers to capture accurate documentation of the patient’s severity of illness and risk of mortality in compliance with all guidelines and requirements.

Provides information and education as necessary to providers on an ongoing basis. Collaborates with Physician Advisor to present specialty specific and/or individual education. Independently attends provider service line or team meetings to serve as a resource and/or educate on documentation opportunities.

Volunteers for special projects in the department such as developing education materials/presentations, tip sheets, present teaching opportunities to co-workers, etc.

Functions as a subject matter expert and actively participates in the department as a problem-solver.

Serves as a mentor to co-workers and a preceptor to new staff.

Serves as a CDI department liaison for provider and/or administrative meetings or internal hospital committees as indicated.

Complies with all applicable laws, regulations, policies, and procedures, supporting the health system’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violations of applicable rules, and cooperating fully with all…