Clinical Documentation Specialist – Inpatient RN
Facility: Scripps Health Corp
Location: San Diego, CA (Remote)
Career Area: Health Information
Employment Type: Full Time
Shift: Day
Job ID: 252001708
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Scripps Health Administrative Services supports our five hospital campuses, 31 outpatient centers, clinics, emergency rooms, urgent care sites, along with our 17,000 employees, more than 3,000 affiliated physicians and 2,000 volunteers.
Healthcare is constantly changing and so is our workplace. Scripps Health continues to build a flexible work culture that supports a work-life balance consisting of flexible work schedules and full-time remote or hybrid remote opportunities in San Diego County. Now you can surround yourself, virtually, with people who are dedicated to making a difference in how we care for our patients, bringing your purpose to life through the work that you do.
Job Description
This is a Full-Time (80 hours every two weeks) benefited and salaried position working day shifts (Sun – Thursday or Tues – Sat). This is a remote position and the candidate must be local in San Diego.
Join the Scripps Health team and work alongside passionate caregivers and provide patient-centered healthcare. Receive endless appreciation while you build a rewarding career with one of the most respected healthcare organizations nationwide.
In this role, you will have the opportunity to join Scripps Centralized Clinical Documentation team. You will provide concurrent review of the clinical documentation in the inpatient medical record to assist in properly reflecting the patient acuity; review the medical record with a clinical lens to identify any missing or understated diagnoses.
As a Clinical Documentation Specialist, you will:
- Review inpatient records for our five Scripps Health hospitals.
- Facilitate improvement in medical record documentation by interacting with and educating physicians, nurses and coding staff to ensure medical records accurately reflect patient acuity for quality reporting and insurance reimbursement.
- Understand the importance that this clinical documentation work has and how it has the prospect to make a large impact enterprise-wide and support a high-quality patient experience.
- Complete admission reviews and work closely with coding staff to ensure accuracy in code assignments that reflect the patient’s clinical status and care.
- Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record. Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient’s discharge.
- Maintain accurate records of review activities, ensuring reports and outcomes of clinical documentation improvement (CDI) efforts are valid.
- Provide education to the healthcare team on an ongoing basis regarding documentation opportunities, coding, and reimbursement issues, and relevant quality and performance improvement activities.
- Provide a concurrent review of the clinical documentation in the inpatient medical record to assist in properly reflecting the patient acuity; review the medical record with a clinical lens to identify any missing or understated diagnoses
Required Education/Experience/Specialized Skills:
- CA RN License or MD required.
- Experienced in using electronic medical records and computer applications.
- Excellent communication and critical thinking skills.
- Strong leadership qualities including the ability to motivate, teach and facilitate individuals and groups on reaching objectives of program.
- Ability to review and interpret clinical information and knowledge of hospital regulatory requirements desired.
- Computer literacy and ability to efficiently and effectively obtain clinical information from a variety of sources necessary.
Preferred Education/Experience/Specialized Skills/Certification:
- Bachelors preferred.
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)
- Registered Health Information Administrator (RHIA)
- Professional work experience as an inpatient Clinical Documentation Specialist.
In compliance with the California Pay Transparency Act, Scripps Health posts the pay range for all jobs. Please note that actual pay will be determined based on relevant experience and internal equity within the pay range. Please also note this range is applicable for employees who reside in California only. A geographical pay differential may be applied for remote employees who reside out of state. Scripps Health strives to ensure that our employees receive equal pay for equal work in line with our commitment to being an equal opportunity employer.
Scripps Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex (including pregnancy, sexual orientation, or gender identity/expression), age, marital status, status as a protected veteran, among other things, or status as a qualified individual with disability.
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About Us
At Scripps, we seek dedicated, compassionate people to join our team and make a significant impact on the health of our community and the future of health care. Throughout our five hospital campuses, 30 outpatient centers and clinics, and hundreds of affiliated physician offices throughout the region, each member of our team plays a key role in our life-changing and life-saving mission. Scripps Health is the only San Diego-based company to make Fortune magazine’s 100 Best Places to Work. Our people and their commitment to the highest standards of care are what define us.
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