Providence RN Clinical Documentation Specialist in Missoula, Montana
Providence is calling a Registered Nurse (RN) Clinical Documentation Specialist (Clinical Documentation, Day Shift, 1.0 FTE, Exempt) to Providence Saint Patrick Hospital in Missoula, Montana. We are a community of caregivers delivering every day on our Mission to provide compassionate care that is accessible for all – especially those who are poor and vulnerable.
In this position you will:
Assist in screening process, making referrals, interacting with case managers and clinical nurse specialists to ensure continuity of patient care as needed.
Conduct follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s chart.
Confer with coding specialists concurrently to ensure appropriate DRG and completeness of supporting documentation.
Confer with hospital “quality team” to ensure completeness of quality data and identify areas for performance improvement.
Educate all internal customers on compliant documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
Identify cases subject to quality monitoring and begins to screen charts for documentation to support quality indicators.
Identify the most appropriate principle diagnosis and CC’s including date to accurately reflect severity of illness in compliance with government regulations.
Process discharges by updating the DRG Worksheet and Quality Worksheet to reflect any changes in status, procedures/treatments, and conferring with physician to finalize diagnoses and documentation of quality measures.
Review charts and completes CDMP® DRG and Quality worksheet.
Assist with management of CDMPTrak®.•Functions as a resource for nursing and ancillary staff concerning estimated length of stay, avoidable hospital days and medical staff utilization management.
Review clinical issues with coding staff to assign a working DRG.
Serve as a member of the CDMP® Task Force.•Working collaboratively and cooperating with other departments/units.•Presents in-services or other educational offerings as assigned.
Required qualifications for this position include:
Current licensure in the State of Montana as a Registered Nurse
Five (5) years recent clinical experience in a hospital setting
Preferred qualifications for this position include:
Associate or Bachelor's Degree in Nursing (BSN)
ICU and/or Critical Care experience
About the ministry you will serve.
Providence St. Patrick Hospital in Missoula, Montana has more than 250 licensed beds and serves patients from 17 counties. We have been recognized as a Thomson Reuters Top 100 Hospital and among many other awards, have earned the Premier Award for Quality award repeatedly. Missoula is halfway between Yellowstone and Glacier National Park. It is a university city of 65,000, surrounded by big sky, scenic mountains, forests and renowned rivers.
For information on our comprehensive range of benefits, visit:
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence is a comprehensive not-for-profit network of hospitals, care centers, health plans, physicians, clinics, home health care and services continuing a more than 100-year tradition of serving the poor and vulnerable. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Case Management
Req ID: 290419