clinical documentation specialist

Valley Medical Center

<div></div><div><div><div><ul><li><h6 class="jobSectionHeader"><b>Job Title:</b></h6>
 Clinical Documentation Specialist
</li><li><h6 class="jobSectionHeader"><b>Req:</b></h6>
 2026-0293
</li><li><h6 class="jobSectionHeader"><b>Location:</b></h6>
 VMC Main Campus
</li><li><h6 class="jobSectionHeader"><b>Department:</b></h6>
 Health Information Mgmt
</li><li><h6 class="jobSectionHeader"><b>Shift:</b></h6>
 Days
</li><li><h6 class="jobSectionHeader"><b>Type:</b></h6>
 Full Time
</li><li><h6 class="jobSectionHeader"><b>FTE:</b></h6>
 1
</li><li><h6 class="jobSectionHeader"><b>Hours:</b></h6>
</li><li><h6 class="jobSectionHeader"><b>City State:</b></h6>
 Renton, WA
</li><li><h6 class="jobSectionHeader"><b>Salary Range:</b></h6>
 Min $94,894 - Max $142,341/annual DOE</li></ul></div></div><br>
<br>
<br>
<br>
<p></p><p><b>Job Description:</b></p>
<p>VALLEY MEDICAL CENTER</p>
<p>
</p><p><b>JOB DESCRIPTION</b></p>
<p>
</p><p>The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.</p>
<p>
</p><p><b>TITLE:</b> Clinical Documentation Specialist RN</p>
<p>
</p><p><b>JOB OVERVIEW:</b> The Clinical Documentation Specialist position facilitates accurate documentation for severity of illness and quality in the medical record. This involves extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the documentation improvement process is a key role.</p>
<p>
</p><p><b>DEPARTMENT:</b> Health Information Management</p>
<p>
</p><p><b>HOURS OF</b> <b>WORK:</b> Days Monday - Friday.</p>
<p>
</p><p><b>RESPONSIBLE TO:</b> Manager, Clinical Documentation Improvement</p>
<p>
</p><p>PREREQUISITES:</p>
<div>
<ul><li><p>Current unrestricted WA State Registered Nurse license, required.</p>
</li></ul>
<ul><li><p>Bachelor's degree in Nursing, preferred.</p>
</li></ul>
<ul><li><p>Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review</p>
</li></ul>
<ul><li><p>Pass a pre-hire Clinical Exam with a minimum score of 70%</p>
</li></ul>
<ul><li><p>Effective communication with Providers</p>
</li></ul>
</div><p></p><p>QUALIFICATIONS:</p>
<div>
<ul><li><p>Knowledge of hospital clinical practice standards for physicians and other health care providers.</p>
</li></ul>
<ul><li><p>Knowledge of ancillary service departments, quality control and safety standards.</p>
</li></ul>
<ul><li><p>Critical thinking, problem solving and deductive reasoning skills.</p>
</li></ul>
<ul><li><p>Familiarity with health care audit and research design.</p>
</li></ul>
<ul><li><p>Knowledge of Pathophysiology and Disease process.</p>
</li></ul>
<ul><li><p>Functional knowledge of DRG coding systems.</p>
</li></ul>
<ul><li><p>Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.</p>
</li></ul>
<ul><li><p>Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.</p>
</li></ul>
<ul><li><p>Meet productivity guidelines.</p>
</li></ul>
<ul><li><p>Ability to learn/develop the skills necessary to perform and meet goal standards</p>
</li></ul>
<ul><li><p>Organizational, analytical, writing, and interpersonal skills</p>
</li></ul>
<ul><li><p>Dependable, self-directed, and pleasant</p>
</li></ul>
<ul><li><p>Critical thinking, problem solving and deductive reasoning skills</p>
</li></ul>
<ul><li><p>Knowledge of Pathophysiology and Disease Process</p>
</li></ul>
<ul><li><p>Basic Computer skills - familiarity with Windows based software programs</p>
</li></ul>
<ul><li><p>Knowledge of regulatory environment</p>
</li></ul>
<ul><li><p>Understand and support documentation strategies (upon completion of training)</p>
</li></ul>
<ul><li><p>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)</p>
</li></ul>
</div><p></p><p>UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT AND WORKING CONDITIONS:</p>
<p>
See Generic Job Description for Administrative Partner.</p>
<p>
</p><p>PERFORMANCE RESPONSIBILITIES:</p>
<p>
A. Generic Job Functions: <i>See Generic Job Description for Administrative Partner.</i></p>
<p>
B. Essential Responsibilities and Competencies</p>
<div>
<ul><li><p>Reviews EMR for completeness and accuracy for severity of illness and quality using the documentation strategies.</p>
</li></ul>
<ul><li><p>Accurate and timely record review.</p>
</li></ul>
<ul><li><p>Recognize opportunities for documentation improvement.</p>
</li></ul>
<ul><li><p>Initiates severity worksheet for inpatients.</p>
</li></ul>
<ul><li><p>Formulate clinically credible documentation clarifications.</p>
</li></ul>
<ul><li><p>Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety.</p>
</li></ul>
<ul><li><p>Effective and appropriate communication with physicians.</p>
</li></ul>
<ul><li><p>Timely follow up on all cases and resolution of those with clinical documentation clarifications.</p>
</li></ul>
<ul><li><p>Communicates with HIM staff and resolves discrepancies.</p>
</li></ul>
<ul><li><p>Accurate input of data for reconciliation of case.</p>
</li></ul>
<ul><li><p>Provide necessary information and education to physicians and staff to facilitate the appropriate documentation goals.</p>
</li></ul>
<ul><li><p>Identify any barriers to completion of documentation goals with appropriate interventions.</p>
</li></ul>
<ul><li><p>Review of regulations and coding guidelines through seminars, meetings, and materials.</p>
</li></ul>
<ul><li><p>In cooperation with the director of PFS/HIM, present education sessions to physicians and other VMC providers regarding documentation regulations and chart audit findings.</p>
</li></ul>
<ul><li><p>Maintains confidentiality of all accessible patient financial or medical records information.</p>
</li></ul>
<ul><li><p>Demonstrates the awareness of the importance of cost containment for the department. Provide suggestions regarding process or quality improvement opportunities to department manager.</p>
</li></ul>
<ul><li><p>Other duties as assigned to facilitate accurate, timely patient account management.</p>
</li></ul>
</div><p></p><p>Date Created: 5/18, updated 7/22</p>
<p>
Grade: NC11</p>
<p>
FLSA: E</p>
<p>
Cost Center: 8490</p><br>
<p><b>
Job Qualifications:</b></p>
<p>PREREQUISITES:</p>
<div>
<ul><li><p>Current unrestricted WA State Registered Nurse license, required.</p>
</li></ul>
<ul><li><p>Bachelor's degree in Nursing, preferred.</p>
</li></ul>
<ul><li><p>Minimum five years recent clinical experience as an RN working in an acute care setting or with experience in Utilization Review</p>
</li></ul>
<ul><li><p>Pass a pre-hire Clinical Exam with a minimum score of 70%</p>
</li></ul>
<ul><li><p>Effective communication with Providers</p>
</li></ul>
</div><p></p><p>QUALIFICATIONS:</p>
<div>
<ul><li><p>Knowledge of hospital clinical practice standards for physicians and other health care providers.</p>
</li></ul>
<ul><li><p>Knowledge of ancillary service departments, quality control and safety standards.</p>
</li></ul>
<ul><li><p>Critical thinking, problem solving and deductive reasoning skills.</p>
</li></ul>
<ul><li><p>Familiarity with health care audit and research design.</p>
</li></ul>
<ul><li><p>Knowledge of Pathophysiology and Disease process.</p>
</li></ul>
<ul><li><p>Functional knowledge of DRG coding systems.</p>
</li></ul>
<ul><li><p>Working experience with Utilization Review activities and general knowledge of JCAHO, PRO, HCFA, and other regulatory bodies.</p>
</li></ul>
<ul><li><p>Knowledge of third-party payer review, reimbursement systems and utilization monitoring requirements for acute care facilities.</p>
</li></ul>
<ul><li><p>Meet productivity guidelines.</p>
</li></ul>
<ul><li><p>Ability to learn/develop the skills necessary to perform and meet goal standards</p>
</li></ul>
<ul><li><p>Organizational, analytical, writing, and interpersonal skills</p>
</li></ul>
<ul><li><p>Dependable, self-directed, and pleasant</p>
</li></ul>
<ul><li><p>Critical thinking, problem solving and deductive reasoning skills</p>
</li></ul>
<ul><li><p>Knowledge of Pathophysiology and Disease Process</p>
</li></ul>
<ul><li><p>Basic Computer skills - familiarity with Windows based software programs</p>
</li></ul>
<ul><li><p>Knowledge of regulatory environment</p>
</li></ul>
<ul><li><p>Understand and support documentation strategies (upon completion of training)</p>
</li></ul>
<ul><li><p>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)</p></li></ul></div></div><p></p>

Clinical Documentation Specialist

Rochester Regional Health

<div><p><b>SUMMARY</b></p><p>
The CDS facilitates accurate documentation for severity of illness, expected risk of mortality, complexity of care and quality in the medical record. This involves extensive record review and interaction with members of the healthcare team and ancillary teams.</p><p></p><p><b>
STATUS: Full-time</b></p><p><b>
LOCATION: Remote</b></p><p><b>
DEPARTMENT: Clinical Documentation
</b></p><p><b>SCHEDULE: Day shift</b></p><p></p><p><b>
ATTRIBUTES</b></p><ul><li>Ability to learn/develop the skills necessary to perform the CDS role</li><li>Organizational, analytical, writing and interpersonal skills</li><li>Dependable, self-directed and pleasant</li><li>Critical thinking, problem solving and deductive reasoning skills</li><li>Knowledge of Pathophysiology and Disease Process</li><li>Basic Computer skills &ndash; familiarity with Windows based software programs</li><li>Knowledge of regulatory environment</li><li>Understand and support CDS documentation strategies (upon completion of training)</li><li>Understand and communicate differences between Medicare Part A and Part B guidelines and how they impact DRG assignments (upon completion of training)</li><li>Knowledge of Core Measure and Patient Safety Indicators (upon completion of training)</li><li>For Skilled Nursing Facility Only:</li></ul>
a. Understand Medicare Part A guidelines<br>
b. Understand the current FY SNF PPS Final Rule<br>
c. Understand the CMS Clinical Category Crosswalk tool for PDPM ICD-10-CM Mappings<br>
d. Understand the MDS Resident Assessment Instrument (RAI) Manual<br>
e. Ability to use the CMS PDPM Calculator Tool<div><br>
Minimum Qualifications:<br>
<ul><li>3-5 years of adult acute care experience in med/surg., critical care, emergency room, or PACU.</li><li>Registered nursing degree required, BSN preferred. Other clinical education may be considered, such as PA, NP, or MD.</li><li>Previous CDS experience preferred</li></ul></div><ul><li>For Skilled Nursing Facility Only:</li></ul>
a. 3 years of patient care, or CDI or Coding experience in an adult population, acute care or skilled nursing facility<br>
b. Registered Nursing Degree required, BSN preferred, or other clinical education may be considered such as LPN, PA, NP, or MD.<br>
OR a degree in Health Information Management (Associate&rsquo;s Degree with RHIT; Bachelor&rsquo;s Degree with RHIA)<p><br>
Required Licensure/Certification:<br>
RN, PA, NP, MBBS or MD prepared candidates.<br>
If hired after January 1, 2017: Must obtain CCDS certification within 30 months of hire.</p><p>
For Skilled Nursing Facility Only:<br>
Valid RN or LPN license, or other applicable professional license, or RHIT, or RHIA</p><p>
Rochester General Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran</p><p></p><p><b>
RESPONSIBILITIES</b></p><ul><li><ul><li>Reviews medical record for completeness and accuracy for severity of illness (SOI), risk of mortality (ROM), complexity of care, and quality</li><li>Accurate and timely record review</li><li>Recognize opportunities for documentation improvement</li><li>Formulate clinically credible documentation clarifications</li><li>Request documentation clarifications as appropriate for SOI, ROM, Complexity of Care, Core Measures, and Patient Safety</li><li>Effective and appropriate communication with physicians</li><li>Provides education to members of the patient care team regarding the CDS process.</li><li>Timely follow up on all cases and resolution of those with clinical documentation clarifications</li><li>Actively participate in Team Meetings</li><li>Manage multiple priorities</li><li>Communicates with HIM staff and resolves discrepancies</li><li>Accurate input of data into department software</li><li>For Skilled Nursing Facility Only:</li></ul>
a. Utilize the ICD-10-CM Official Guidelines for Coding &amp; Reporting and their application in the long-term healthcare setting.<br>
b. Utilize an ICD-10-CM indexing system to determine appropriate ICD-10-CM codes.<br>
c. Collaborate with the hospital and skilled nursing facility (SNF) team members to ensure documentation supports the most specified, appropriate, and billable ICD-10-CM code(s) for primary and secondary diagnoses (co-morbidities) to be assigned for a SNF authorization, and PPS assessments required under PDPM.</li></ul><p></p><p>
#RRHProfessional26</p><p></p><p><b>
EDUCATION:</b></p><p></p><p><b>
LICENSES / </b><b>CERTIFICATIONS:</b></p>
RN - Registered Nurse - New York State Education Department (NYSED)<p></p><p><b>
PHYSICAL REQUIREMENTS:</b></p>
S - Sedentary Work - Exerting up to 10 pounds of force occasionally Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.<p></p><p><b>
For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.</b><b>
</b></p><p></p><p><b>Any physical requirements reported by a prospective employee and/or employee&rsquo;s physician or delegate will be considered for accommodations.
</b></p><p></p><p><b>PAY RANGE:</b></p>
$78,000.00 - $95,000.00<p></p><div><div><div><div><div><div><div><p><b>
CITY:</b></p></div></div></div></div></div></div></div>
Rochester<p></p><div><div><div><div><div><div><div><p><b>
POSTAL CODE:</b></p></div></div></div></div></div></div></div>
14621<p></p><p><b><i>
The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.</i></b></p><p></p><p><b>
Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.</b></p></div>

Ascension

<div>We Are Hiring:
<div><b>
Location: </b>Remote</div><div><b>
Facility: </b>Ascension Wisconsin Hospitals</div><div><b>
Department/Specialty: </b>Clinical Integrity Documentation</div><div><b>
Schedule: </b>Days | Full Time</div><div><b>
Salary Range:</b> $79,511.52-$110,834.59</div>
What You Will Do:
<div>
Facilitate improvement in overall quality, completeness and accuracy of medical record documentation.</div><ul><li>
Complete admission reviews and assign a working Diagnosis Related Group. Ensure the working DRG and other information are entered in the Clinical Documentation Improvement database.</li><li>
Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.</li><li>
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.</li><li>
Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.</li></ul>
What You Will Need:
<div>
Licensure / Certification / Registration:</div><ul><li>
One or more of the following required:<ul><li>
Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.</li><li>
Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.</li><li>
Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.</li><li>
Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.</li><li>
Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.</li><li>
Licensed Registered Nurse credentialed from the Wisconsin Board of Nursing or current home state license for multi-state license recognition &quot;Compact State&quot; obtained prior to hire date or job transfer date.</li></ul></li></ul><div>
Education:</div><ul><li>
High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.</li></ul>
Additional Preferences:
<ul><li>5 or more years of nursing experience in ICU and/or Emergency Department</li><li>
Previous Clinical Documentation Specialist experience</li></ul>
Why Join Our Team:
<div>
Ascension is a leading nonprofit Catholic health system with a culture and associate experience grounded in service, growth, care and connection. We empower our 99,000+ associates to bring their skills and expertise every day to reimagining healthcare, together. Recognized as one of the Best 150+ Places to Work in Healthcare and a Military-Friendly Gold Employer, you&rsquo;ll find an inclusive and supportive environment where your contributions truly matter.</div>
Equal Employment Opportunity Employer:
<p><b><i>
Equal employment opportunity employer
</i></b></p><p>Ascension provides Equal Employment Opportunities (EEO) to all associates and applicants for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy, childbirth, and related medical conditions, lactation, breastfeeding, national origin, citizenship, age, disability, genetic information, veteran status, marital status, all as defined by applicable law, and any other legally protected status or characteristic in accordance with applicable federal, state and local laws. For further information, view the EEO Know Your Rights (English) poster or EEO Know Your Rights (Spanish) poster.</p><p><b><i>
Fraud prevention notice
</i></b></p><p>Prospective applicants should be vigilant against fraudulent job offers and interview requests. Scammers may use sophisticated tactics to impersonate Ascension employees. To ensure your safety, please remember: Ascension will never ask for payment or to provide banking or financial information as part of the job application or hiring process. Our legitimate email communications will always come from an @ascension.org email address; do not trust other domains, and an official offer will only be extended to candidates who have completed a job application through our authorized applicant tracking system.</p><p><b><i>
E-Verify statement</i></b></p><div>
Employer does not participate in E-Verify and therefore cannot employ STEM OPT candidates.</div>
Benefits:
<div>
Paid time off (PTO)<br>
Various health insurance options &amp; wellness plans<br>
Retirement benefits including employer match plans<br>
Long-term &amp; short-term disability<br>
Employee assistance programs (EAP)<br>
Parental leave &amp; adoption assistance<br>
Tuition reimbursement<br>
Ways to give back to your community</div><div></div><div><i><br>
Benefit options and eligibility vary by position. Compensation varies based on factors including, but not limited to, experience, skills, education, performance, location and salary range at the time of the offer.</i></div></div>

DHR Health

<div><p>DHR Health - US:TX:Rio Grande City - Days
</p><p>Summary:<br>
<br>
</p><p><b>FLSA STATUS:</b><b> </b><b>Exempt</b><b> </b><b>Non-Exempt
</b></p><p></p><p><b>MISSION STATEMENT:
</b></p><p>Our Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every encounter, every time.
</p><p></p><p><b>VISION:
</b></p><p>Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence.<br>
</p><p></p><p><b>POSITION SUMMARY:
</b></p><p>The Primary role of a Clinical Documentation Specialist is to assist the physician with the complete documentation of patients&rsquo; charts. Clinical Documentation Specialists accompany the physician as he/she examines and interviews patients and then records the physician&rsquo;s observations and comments on either on paper or in an electronic medical record (EMR) depending on what the practice uses. Clinical Documentation Specialist will accompany physician on hospital rounds and consultations if required. All information is recorded in the presence of a physician, as dictated by the physician.<br>
</p><p></p><p><b>POSITION EDUCATION/ QUALIFICATIONS </b><b>:
</b></p><p>&middot; High School graduate or equivalency is preferred.
</p><p>&middot; Medical Terminology required.
</p><p>&middot; CNA or Medical Assistant certification from an accredited school preferred.
</p><p>&middot; Excellent customer service skills.
</p><p>&middot; Computer skills required with knowledge of Microsoft Office suite.
</p><p>&middot; Good written and verbal communication skills required.
</p><p>&middot; Bilingual &ndash; English/Spanish.
</p><p></p><p><b>JOB KNOWLEDGE/EXPERIENCE </b><b>:
</b></p><ul><li>One (1) year experience in a hospital or physician office setting is preferred
</li></ul><ul><li>Previous experience as a medical scribe preferred
</li></ul><ul><li>Demonstrates proficiency in Microsoft Office applications
</li></ul><ul><li>Previous experience with an EMR system preferred
</li></ul><ul><li>Must have excellent customer service and organizational skills
</li></ul><ul><li>Requires reasoning ability and good independent judgment<br>
</li></ul><p></p><p>Responsibilities:<br>
<br>
</p><p><b>POSITION RESPONSIBILITIES:
</b></p><ul><li>Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices
</li></ul><ul><li>Keep track of laboratory tests, medications, and radiology tests ordered by the physician
</li></ul><ul><li>Gather data for physician review (i.e., laboratory results, faxed radiology reports, medical records)
</li></ul><ul><li>Coordinate communication between physicians and staff, make and answer telephone calls
</li></ul><ul><li>Document any consultations the physician makes to a patient&rsquo;s personal doctor, family members, on-call physician, or other members of the medical community
</li></ul><ul><li>Take vital signs and room patients as needed
</li></ul><ul><li>Accompany provider to hospital to document consults or hospital rounds as needed
</li></ul><ul><li>Provide patients with updates about waits and delays
</li></ul><ul><li>Document all procedures done by the physician, as dictated by the physician
</li></ul><ul><li>Responsible for documenting all diagnoses, treatment plans, prescriptions, and discharge/follow-up information for each patient
</li></ul><ul><li>Other duties as assigned<br>
</li></ul><p></p><p><b>LINES OF REPSONSIBILITIES </b><b>:
</b></p><p>(Chain-of-command)
</p><p>1. Clinic Manager 2. Director of DHR Health Clinics 3. Chief Ambulatory Officer<br>
</p><p></p><p>Other information:<br>
<br>
</p><p><b>CUSTOMER SERVICE:
</b></p><p>Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service.<br>
</p><p></p><p><b>AGE SPECIFIC </b>:
</p><p>Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient&rsquo;s status and interpret the appropriate information needed to identify each patient&rsquo;s requirement relative to his or her age.
</p><p></p><p><b>AMERICANS WITH DISABILITIES ACT: (ADA) </b>:
</p><p></p><p>A. <b>Essential Duties </b>: Indicated by bold print within performance standards, preceding individual numbered criteria.
</p><p></p><p><b>The following table provides physical requirements that will be associated with, but not limited to, this position:
</b></p><p></p><div><div><div><div><p>Light/moderate lifting up to 20 lbs, from the floor to shoulder height.<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Kneeling<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Must be able to assist other employees with lifting more than 20 lbs.<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Walking<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Light/moderate carrying up to 20 lbs.<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Standing/Squatting<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Straight pulling<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Sitting<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Pulling hand over hand<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Pushing<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Repeated bending<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Stooping/Bending<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Reaching above shoulder<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Climbing Stairs<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Simple grasping<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Climbing Ladders<br>
</p></div><div><p>No<br>
</p></div></div><br>
<div><div><p>Dual simultaneous grasping<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Depth Perceptions needed<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Ability to see<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Identify Colors<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Operating office equipment<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Twisting<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Operating mechanical equipment<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Crawling<br>
</p></div><div><p>No<br>
</p></div></div><br>
<div><div><p>Ability to read and write<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Ability to Count<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Ability to hear verbal communication without aid<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Operating Personal Vehicle<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>Ability to comprehend written/verbal communication<br>
</p></div><div><p>Yes<br>
</p></div><div><p>Other: Ability to deal with stress<br>
</p></div><div><p>Yes<br>
</p></div></div><br>
<div><div><p>OSHA Category<br>
</p></div><div><p>III<br>
</p></div></div><br>
</div></div><p></p><p>B. <b>Working Conditions </b><b>: </b>The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents.
</p><p></p><p>C. <b>Occupational Exposure: </b>This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.
</p><p></p><p>D. <b>Aptitudes </b><b>: HIGH 1 2 3 4 5 6 LOW
</b></p><p></p><p><b>Intelligence: </b>General learning ability: The ability to &ldquo;catch on&rdquo; or understand instructions and underlying principles. Ability to reason and make judgments. <b>3
</b></p><p></p><p><b>Verbal: </b>Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. <b>3
</b></p><p></p><p><b>Numerical: </b>Ability to perform arithmetic operations quickly and accurately. <b>2
</b></p><p></p><p><b>Spatial: </b>Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to &ldquo;visualize&rdquo; objects or two or three dimensions, or to think visually of geometric forms. <b>2
</b></p><p></p><p><b>Form Perception: </b>Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. <b>3
</b></p><p></p><p><b>Clerical Perception: </b>Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. <b>2
</b></p><p></p><p><b>Motor Coordination: </b>Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly. <b>3
</b></p><p></p><p><b>Finger Dexterity: </b>Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. <b>3
</b></p><p></p><p><b>Manual Dexterity: </b>Ability to move hands easily and skillfully. To work with hands in placing and turning motions. <b>3
</b></p><p></p><p><b>Eye-Hand-Foot Coordination: </b>Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. <b>3
</b></p><p></p><p><b>Color Discrimination: </b>Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately. <b>3
</b></p><p></p><p>I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform.
</p><p></p><p>If applicable ____________ certification will be completed within _________ time frame of hire/transfer date.
</p><p></p><p>Employee Signature: ________________________________ Date: ____________________
</p><p></p><p>Transfer/Hire Date Effective: ________________________.</p></div>

Clinical Documentation Specialist - FT - Days - Cardiology (Dr. Menon - Rio Grande City)

Tidelands Health

<div>
 Employee Type:
 <br/>
 <br/>
 Regular
 <br/>
 <br/>
 Work Shift:
 <br/>
 <br/>
 Day - 8 hour shift (United States of America)
 <br/>
 <br/>
 <strong>
  Join Team Tidelands and help people live better lives through better health!
  <br/>
  <br/>
 </strong>
 <strong>
  Clinical Documentation Improvement Specialist (RN) (3419)
  <br/>
  <br/>
 </strong>
 Are you passionate about quality and committed to excellence? Consider joining our Tidelands Health team. As our region's largest health care provider, we are also one of our area's largest employers. More than 2,500 team members at more than 70 Tidelands Health locations bring our healing mission to life each day.
 <br/>
 <br/>
 <strong>
  A Brief Overview
  <br/>
  <br/>
 </strong>
 The Clinical Documentation Improvement Specialist (RN) is a hybrid role that combines the expertise of clinical documentation improvement (CDI) and outpatient Hierarchical Condition Category (HCC) coding. This position will report to the Outpatient CDI Program Manager. This position focuses on improving the accuracy, quality, and completeness of clinical documentation in outpatient medical records while ensuring compliance with coding guidelines. The specialist will work collaboratively with providers, coding teams, and other healthcare professionals to facilitate accurate coding, improve risk capture, and optimize reimbursement while reflecting the true severity of illness and care provided.
 <br/>
 <br/>
 <strong>
  Education Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   BSN and a minimum of five years clinical nursing experience Required
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Experience Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   At least 3 or more years' experience either in the clinical field (RN), CDI field, or coding field Required
  </li>
  <li>
   Experience in an outpatient or acute care setting Required
  </li>
  <li>
   1 or more years' experience in HCC/Risk Adjustment Preferred
  </li>
  <li>
   Minimum of 3 years of experience in clinical documentation improvement, outpatient Hierarchical Condition Category (HCC), or a combination of both Preferred
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Skills And Abilities
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Strong clinical experience and critical thinking skills required
  </li>
  <li>
   Extensive knowledge of patient care, and knowledge of clinical measurement, tools, and clinical outcomes
  </li>
  <li>
   Ability to establish cooperative, working relationships with diverse groups and individuals, medical staff and other healthcare disciplines
  </li>
  <li>
   Ability to work independently, be resourceful, and possess strong organizational skills
  </li>
  <li>
   Ability to communicate effectively with physicians and other clinical staff; be courteous and professional
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Licenses and Certifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Registered Nurse - South Carolina Department of Labor, Licensing and Regulation Required
  </li>
  <li>
   Certified Professional Coder - American Academy of Professional Coders within 1 Year Required or
  </li>
  <li>
   Certified Coding Specialist - American Health Information Management Association within 1 Year Required or
  </li>
  <li>
   Certified Clinical Documentation Specialist - Association of Clinical Documentation Integrity Specialist within 1 Year Required
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Physical Demand
  <br/>
  <br/>
 </strong>
 Light Physical Demand
 <br/>
 <br/>
 The intent of this job description is to provide a representative and level of the types of duties and responsibilities that will be required of positions given this title and shall not be construed as a contract for employment nor a declaration of the total of the specific duties and responsibilities of any particular position. Employees may be directed to perform tasks other than those specifically presented in this description.
 <br/>
 <br/>
 Tidelands Health is an Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
 <br/>
 <br/>
 Tidelands Health is an equal opportunity employer (EOE). Tidelands Health does not discriminate against employees or applicants for employment on the basis of race, color, creed, religion, age, national origin, disability, marital status, veteran status, gender, genetic information, familial status, or any other legally protected status.
</div>


Outpatient CDI Specialist (RN)

MyMichigan Health

<div>
 <strong>
  Summary
  <br/>
  <br/>
 </strong>
 The coding specialist, utilizing the clinical documentation management program and clinical knowledge, analyzes inpatient and outpatient medical records for completeness of documentation, contacting the appropriate provider for additional documentation if needed. Accurate diagnosis and procedure codes are then assigned based on the documentation in the medical record, which directly impacts the appropriate DRG assignment for reimbursement. Critical data elements are abstracted by the Coding specialist on all inpatient discharges. This information is used by the organization for decision making.
 <br/>
 <br/>
 <strong>
  Responsibilities
  <br/>
  <br/>
 </strong>
 <strong>
  (60%)*
 </strong>
 Assigns accurate ICD-CM diagnosis and procedure codes and CPT codes in a timely manner for all appropriate encounters and ensures appropriate DRG assignment based on the clinical documentation within the medical record by using CMS and American Hospital Guidelines and following AHIMA code of ethics.
 <br/>
 <br/>
 <strong>
  (30%)*
 </strong>
 Utilizes clinical knowledge to interact with the Clinical Documentation Specialists and physicians/providers on a daily basis to assist in improving documentation within the medical record; to accurately reflect the severity of illness and level of care provided.
 <br/>
 <br/>
 <strong>
  (10%)*
 </strong>
 Demonstrates willingness to participate in continuing education to enhance coding knowledge.
 <br/>
 <br/>
 <strong>
  Other Duties And Responsibilities
  <br/>
  <br/>
 </strong>
 Meets established productivity guidelines.
 <br/>
 <br/>
 Other duties as assigned.
 <br/>
 <br/>
 MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft Windows.
 <br/>
 <br/>
 An employee may be required to participate in further learning opportunities offered by MyMichigan Health.
 <br/>
 <br/>
 Certifications and Licensures
 <br/>
 <br/>
 E/M CODER: CPC, CCS, CCSP, RHIT, OR RHIA
 <br/>
 <br/>
 Effective October 1, 2013, new hires must be RHIA or RHIT eligible and successfully complete the certification exam within six (6) months of hire and maintain the certification to meet the requirements of the position.
 <br/>
 <br/>
 FINGERPRIN: Fingerprinting
 <br/>
 <br/>
 Required Education
 <br/>
 <br/>
 Associates degree is required
 <br/>
 <br/>
 Other Information
 <br/>
 <br/>
 <strong>
  Experience, Training And Skills
  <br/>
  <br/>
 </strong>
 Coding experience from an AHIMA approved internship required or successfully completed an independent study program offered by AHIMA.
 <br/>
 <br/>
 Knowledge of medical terminology and anatomy.
 <br/>
 <br/>
 Written, oral, organizational and interpersonal skills needed to communicate successfully.
 <br/>
 <br/>
 <strong>
  Physical/Mental Requirements And Typical Working Conditions
  <br/>
  <br/>
 </strong>
 Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death.
 <br/>
 <br/>
 Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position.
 <br/>
 <br/>
 Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description.
 <br/>
 <br/>
 Overall vision and hearing is necessary with or without assisted device(s).
 <br/>
 <br/>
 Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching.
 <br/>
 <br/>
 Some exposure to blood borne pathogens and other potentially infectious material
 <br/>
 <br/>
 Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.
 <br/>
 <br/>
 Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis.
 <br/>
 <br/>
 Physical Demand Level:
 <strong>
  Sedentary.
 </strong>
 Must be able to occasionally (0-33% of the workday) lift or carry 0-10 lbs.
</div>


Coder II

Oak Street Health, part of CVS Health

<div><p>We&rsquo;re building a world of health around every individual &mdash; shaping a more connected, convenient and compassionate health experience. At CVS Health&reg;, you&rsquo;ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger &ndash; helping to simplify health care one person, one family and one community at a time.</p><p></p><p><b>
Title: </b>Medical Scribe</p><p></p><p><b>
Company: </b>Oak Street Health</p><p></p><p><b>
Role Description:</b></p><p></p><p>
The purpose of a Clinical Informatics Specialist (CIS or Medical Scribe) at Oak Street Health is to support our primary care providers with clinical documentation so that they can focus on providing exceptional care to our patients. Scribes assist providers throughout the patient care journey - huddling each morning to plan for the day's visits, joining them in the exam room to observe and document, and touching base after the visit to assist with next steps.</p><p></p><p>
Beyond the typical Scribe role, these important care team members serve as clinical documentation assistants to their paired provider. Internally, we call them CISs (Clinic Informatics Specialists) in recognition of their important role in supporting accurate, specific, and timely clinical documentation. In addition to observing and documenting all patient encounters in real time, our Scribes become experts in our value-based care model and the documentation and care of chronic conditions, including ICD-10 and CPT coding. Scribes use this expertise to help providers identify and help close care gaps. Scribes receive extensive on-the-job training in clinical workflows, value-based medicine, preventative care for chronic conditions, accurate and specific documentation, population health data streams, and team based care.</p><p></p><p>
Because our patients and providers rely on our Scribes, the ideal candidate should commit at least 1-2 years to this role. This is an excellent opportunity for pre-med track individuals looking to gain practical, paid experience in a clinical setting before applying to an MD/DO/PA/NP program, as well as those pursuing careers in Health Informatics, Public Health, Healthcare Administration, Medical Coding, and other related fields.</p><p></p><p><b>
Responsibilities:</b></p><ul><li>
Documenting Patient Encounters ~ 80%<ul><li>
Joining the provider in the exam room to observe patient visits</li><li>
Documenting patient encounters in a structured note, including the history of the present illness, assessment, plan, and physical exam</li><li>
Assigning appropriate CPT and ICD-10 codes</li><li>
Preparing After Visit Summaries</li><li>
Consulting with provider to ensure accurate and specific documentation</li></ul></li><li>
Clinical Documentation Improvement ~ 10%<ul><li>
Requesting and reviewing medical records</li><li>
Leveraging Oak Street's population health tools to support clinical documentation improvement</li><li>
Preparing for and supporting Daily Huddles and Clinical Documentation Reviews</li><li>
Consulting with provider on clinical documentation opportunities</li></ul></li><li>
Administrative support for your provider and care team ~ 10%<ul><li>
Placing orders and referrals</li><li>
Addressing tasks</li><li>
Supporting the care team with additional responsibilities related to clinical documentation</li></ul></li><li>
Other duties as assigned</li></ul><p></p><p><b>
What we're looking for</b></p><p></p><p><b>
Knowledge</b></p><ul><li>
Knowledge of medical terminology and common medications, either from a pre-medical degree or prior clinical experience [required]</li><li>
Prior clinical experience, including shadowing and/or volunteering [strongly preferred]</li><li>
Prior scribe or transcription experience [preferred but not required]</li></ul><p></p><p><b>
Skills</b></p><ul><li>
Advanced listening and communication skills [required]</li><li>
Strong computer literacy and ability to learn new technical workflows [required]</li><li>
Fluency in Spanish, Polish, Russian, or other languages spoken by people in the communities we serve [required where indicated]</li></ul><p></p><p><b>
Abilities</b></p><ul><li>
Ability to adapt to new workflows and to quickly learn new concepts and skills [required]</li><li>
Ability to type 70+ words per minute [strongly preferred]</li><li>
Ability and willingness to take direction and be a member of a team providing patient care, including adapting to the provider's working style [required]</li><li>
Ability to be a self-starter within your role scope</li><li>
Excellent job attendance including ability to work in-person in our clinics (Our providers count on you.) [required]</li><li>
Ability to commit to at least 1 year in role (2+ is ideal) [required]</li><li>
Ability to work approximately 40-45 hours per week during clinic hours (full time position) with predictable hours and break times [required]</li><li>
Compliance with hospital and Oak Street Health policies, including HIPAA [required]</li><li>
US work authorization [required]</li></ul><p></p><p><b>
Anticipated Weekly Hours</b></p>
40<p></p><p><b>
Time Type</b></p>
Full time<p></p><p><b>
Pay Range</b></p><p>
The typical pay range for this role is:</p><p></p>
$17.00 - $28.46<p></p><p>
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.</p><p><br>
Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.</p><p></p><p><b>
Great benefits for great people</b></p><p></p><p>
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.</p><br>
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.<p><br>
Additional details about available benefits are provided during the application process and on Benefits Moments.</p><br>
We anticipate the application window for this opening will close on: 10/24/2026<p></p><p>
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.</p></div>

Medical Scribe

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Clinical Documentation Specialist - FT - Days - Cardiology (Dr. Menon - Rio Grande City)

Outpatient CDI Specialist (RN)

Coder II

Medical Scribe