Clinical Documentation Specialist, Clinician Job at Sutter Health, Sacramento, CA

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  • Sutter Health
  • Sacramento, CA

Job Description

We are so glad you are interested in joining Sutter Health!

Organization

SHSO-Sutter Health System Office-Valley

Position Overview

Conducts concurrent and retrospective reviews of patient medical records to evaluate the accuracy and completeness of clinical documentation, ensuring notes reflect the severity of patient's illness and quality of care. Interacts thoughtfully and effectively with physicians, patient care team, and ancillary departments to gather and clarify medical record documentation. Identifies opportunities for improvement to ensure understanding of documentation requirements, optimize reimbursement for the level of service rendered, and enhance the measurement and reporting of outcomes.

EDUCATION

  • Graduate of an accredited school of nursing OR Foreign trained physician

CERTIFICATION & LICENSURE

  • RN-Registered Nurse of California OR Foreign trained physician
  • CCDS or CDIP certification

TYPICAL EXPERIENCE

  • 5 years recent relevant experience.

SKILLS AND KNOWLEDGE

  • Clinical knowledge of diagnoses, severity of illness, risk of mortality, co-morbidities and complications.
  • Knowledge of age-specific needs and the elements of disease processes and related procedures.
  • Knowledge of current coding classification and reimbursement guidelines and regulations.
  • Critical thinking with the ability to analyze and interpret medical record/clinical documentation and formulate appropriate physician queries.
  • Ability to define issues, collect data, establish facts and draw valid conclusions.
  • Demonstrates a proactive approach in identifying and addressing issues and concerns.
  • Collaboration skills to facilitate open sharing of information and cooperation with various stakeholders to problem solve and achieve desired results/outcome.
  • Displays a customer service focus in all decisions and actions.
  • Ability to communicate through verbal and written means, and to present information to a variety of audiences.
  • Ability to create and translate data into reports and presentations for appropriate audience.
  • Organization skills to effectively manage and/or re-prioritize activities and projects to meet deadlines while maintaining a high degree of responsiveness.
  • Ability to interact and maintain effective working relationships with those contacted in the performance of required duties.
  • Demonstrates respect for cultural and linguistic differences and promotes an inclusive work environment.
  • Demonstrates initiative in providing feedback/input to improve workflow/processes.
  • Ability to work effectively in a dynamic and fast-paced environment with changing business priorities.
  • Ability to maintain and work discreetly with confidential information.
  • Ability to use essential applications and/or databases associated with the role’s duties and responsibilities.

Job Shift

Days

Schedule

Full Time

Shift Hours

Days of the Week

Variable

Weekend Requirements

None

Benefits

Yes

Unions

No

Position Status

Non-Exempt

Weekly Hours

Employee Status

Regular

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $82.86 to $108.54 / hour. New Jersey, Washington, California Pay Range is $82.85 to $108.54 / hour. Colorado, Florida, Georgia, Illinois, Michigan, Minnesota, Nevada, North Carolina, Ohio, Oregon, Pennsylvania, Texas, Virginia Pay Range is $42.95 to $56.26 / hour. Arizona, Arkansas, Idaho, Louisiana, Missouri, Montana, South Carolina, Tennessee, Utah Pay Range is $39.05 to $51.15 / hour.

The compensation range may vary based on the geographic location where the position is filled. Total compensation considers multiple factors, including, but not limited to a candidate’s experience, education, skills, licensure, certifications, departmental equity, training, and organizational needs. Base pay is only one component of Sutter Health’s comprehensive total rewards program. Eligible positions also include a comprehensive benefits package.

Job Tags

Full time, Work at office, Shift work, Weekend work

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