[Hiring] Clinical Documentation Integrity Specialist @San Juan Regional Medical Center

Role Description

Creating Life Better Here starts with you. At San Juan Regional Medical Center, we're more than a healthcare provider—we're a values-driven organization dedicated to delivering exceptional care. As a team member, you help fulfill our mission to make life better here for our community.

• Facilitates improvement in the quality and completeness of patient records on a concurrent basis, using a multi-disciplinary process.
• Applies clinical knowledge and coding knowledge to evaluate clinical indicators, diagnoses, and treatment plan for assigned inpatients, to identify gaps in physician documentation.

Qualifications

• Registered Nurse - Minimum of three (3) years strong clinical background in acute care
• Current NM Licensure
• Excellent written and verbal communication skills
• Analytical thinking skills
• Team-oriented
• Basic computer skills
• Highly organized

Requirements

• BSN
• Certified Clinical Documentation Specialist (CCDS)
• Coding experience

Duties and Responsibilities

• Comprehensively reviews patient records, concurrently and retrospectively, to assure a complete and accurate representation of the severity of illness and use of resources.
• Assigns Working DRG.
• Works closely with physicians, Case Management staff, and Coding to review documentation coding practices analyzing whether documentation supports the acuity of the patients.
• Identifies gaps in physician documentation and facilitates appropriate documentation improvement interventions with physicians.
• Identifies Clinical Documentation Improvement (CDI) best practices, benchmarks and improvement strategies to augment compliance objectives.
• Stays current on information pertaining to coding, compliance, clinical guidelines and payer requirements as it relates to MSDRG assignment, documentation and other payment requirements.
• Each employee is responsible for implementing SJRMC’s Service Standards into their daily work: Safety, Courtesy, Effectiveness, and Stewardship.
• Other duties as assigned.

Physical Demands and Environmental Work Conditions

• Prolonged standing/sitting/walking
• Fast paced environment
• High level of activity with many interruptions
• Possible exposure to communicable disease
• Repetitive motions (i.e.; keyboard usage)

Sensory Requirements

• The employee will need to be able to hear:
  • Alarms on equipment/fire alarms/overhead announcements
  • Patients/family/physician verbal discussion
  • Feedback from other healthcare providers
• The employee will need to be able to see:
  • Focus on close-up and distant objects
  • Have intact peripheral vision and depth perception