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
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:
- Focus on close-up and distant objects
- Have intact: peripheral vision and depth perception
