Clinical Documentation Integrity Specialist

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.

Required Behaviors:

As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization: Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.

Required 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

Preferred Qualifications:

• •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:

• •F ocus on close-up and distant objects
• •Have intact: peripheral vision and depth perception