Santa Barbara Cottage Health seeks a Clinical Documentation Specialist for their Clinical Documentation department responsible for providing concurrent review of clinical documentation in the medical record ensuring that the physician documentation supports the severity of patient illness and risk of mortality. Major accountabilities include:

•    Provides concurrent and subsequent reviews of the clinical documentation in the medical record using documentation improvement guidelines. Evaluates and identifies gaps in clinical documentation that need clarification for accurate code assignment to ensure overall quality and completeness of the record. The key responsibility is to review the chart for information not currently in the chart but supported by clinical indicators.
•    Queries the medical staff when necessary through written or verbal communication to obtain accurate and complete physician documentation that supports the severity of patient illness and risk of mortality.
 

QUALIFICATIONS:
All job qualifications listed indicate the minimum level necessary to perform this job proficiently. 
 

Education:
•    Minimum: Associate's Degree in Nursing.
•    Preferred: Bachelor’s Degree in Nursing.

Certifications, Licenses, Registrations:
•    Minimum: Current CA RN License.
•    Preferred: Current CA RN License and Certified Clinical Documentation Specialist certification (CCDS and/or CDIP) For candidates without certification, must obtain CCSDS or CDIP certification within 6 months in position or after completing required years in CDI to sit for exam.

Technical Requirements:
•    Minimum: Basic MS office skills; including Excel, Word, Outlook. Basic proficiency in computer applications.
•    Preferred: EPIC, 3M 360, 3M eMD.

Years of Related Work Experience:
•    Minimum: 5 years recent RN nursing experience in an Acute Care Hospital, 3 years of recent experience working in inpatient Clinical Documentation Improvement, and/or completion of ACDIS Apprenticeship Program.
•    Preferred: RN with 6+ years recent clinical experience in an acute care hospital; with preferably Critical Care or ER experience, with CCDS and/or CDIP Certification with 2+ years recent CDI experience.