Senior Clinical Documentation Specialist, PRN (RN required; CCDS or CDIP cert preferred) - REMOTE

Discover Vanderbilt Health: With eight hospitals and over 180 clinics, we are the region’s largest comprehensive academic health system. Vanderbilt Health has a long tradition of providing world-class care to the people of the Mid-South, living out our mission of moving medicine forward through preeminent programs in patient care, education and research. Here you’ll find a spirit of collaboration and a supportive community where your expertise is valued, your knowledge expanded and your uniqueness celebrated. We are committed to fostering an environment where talented, compassionate people are united in bringing the most advanced care to our neighbors throughout the region.

Organization:

HIM - CDE - 3

Job Summary:

JOB SUMMARY
Ensures capture of discharge diagnosis and procedures independently. Documents the patient's clinical status and care provided. Performs concurrent review of patient records for documentation to support assignment of clinical codes.

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KEY RESPONSIBILITIES • Performs assessment of patient records to evaluate documentation for accuracy, legibility and completeness. • Works with coding staff to ensure documentation of discharge diagnoses, including any coexisting co-morbidities, and procedures are complete. • Communicates with providers regarding missing, unclear, or conflicting clinical documentation. • Collaborates with case managers, nursing staff, and other staff on documentation issues and resolves provider queries prior to patient discharge. • Monitors provider documentation queries for timely and compliant response and escalates issues. • The responsibilities listed are a general overview of the position and additional duties may be assigned. TECHNICAL CAPABILITIES • Written Communication (Novice): Demonstrates the ability to write clear, detailed, and comprehensive status reports, memos and documentation. Demonstrates an understanding of effective composition, such as having first line in a paragraph state the subject. • Verbal Communication (Novice): Ability to enunciate clearly, using appropriate voice control and body language. Effectively transmits technical and business ideas and information to others. Listens carefully to ascertain points being made before trying to be understood. • Medical Coding (Intermediate): The transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. • Critical Thinking (Novice): The objective analysis and evaluation of an issue in order to form a judgment. • Relationship Management: Manages internal and external organizational relationships with clients, vendors, partners and staff.

Our professional administrative functions include critical supporting roles in information technology and informatics, finance, administration, legal and community affairs, human resources, communications and marketing, development, facilities, and many more.

At our growing health system, we support each other and encourage excellence among all who are part of our workforce. High-achieving employees stay at Vanderbilt Health for professional growth, appreciation of benefits, and a sense of community and purpose.

Core Accountabilities:

Organizational Impact: Independently delivers on objectives with understanding of how they impact the results of own area/team and other related teams. Problem Solving/ Complexity of work: Utilizes multiple sources of data to analyze and resolve complex problems; may take a new perspective on existing solution. Breadth of Knowledge: Has advanced knowledge within a professional area and basic knowledge across related areas. Team Interaction: Acts as a "go-to" resource for colleagues with less experience; may lead small project teams.

Core Capabilities :

Supporting Colleagues: - Develops Self and Others: Invests time, energy, and enthusiasm in developing self/others to help improve performance e and gain knowledge in new areas. - Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships. - Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences. Delivering Excellent Services: - Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them. - Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions. - Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness. Ensuring High Quality: - Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly. - Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them. - Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring. Managing Resources Effectively: - Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure. - Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area. - Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities. Fostering Innovation: - Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches. - Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges. - Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.

Position Qualifications:

Responsibilities:

Certifications:

LIC-Registered Nurse - Licensure-Others

Work Experience:

Relevant Work Experience

Experience Level:

4 years

Education:

Graduate of an approved discipline specific program (Required)

This role offers the opportunity to make a meaningful impact within Vanderbilt Health, supported by a comprehensive benefits package which may include health, disability, retirement and/or wellness offerings to enhance your well-being and professional growth.

Vanderbilt Health is committed to fostering an environment where everyone has the chance to thrive and is committed to the principles of equal opportunity.  EOE/Vets/Disabled.