Billings Clinic Clinical Documentation Specialist RN - Inpatient in Billings, Montana
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Billings Clinic is a community-owned, not-for-profit, Physician-led health system based in Billings with more than 4,700 employees, including over 550 physicians and non-physician providers. Our integrated organization consists of a multi-specialty group practice and a 304-bed hospital.Learn more (https://www.billingsclinic.com/about-us/) about Billings Clinic (our organization, history, mission, leadership and regional locations) and how we are recognized nationally for our exceptional quality.
We provide a comprehensive and competitive benefits package to all full-time employees (minimum of 24 hours/week), including Medical, Dental, Vision, 403(b) Retirement Plan with employer matching, Defined Contribution Pension Plan, Paid Time Off, employee wellness program, and much more.Click here (https://www.billingsclinic.com/careers/employee-benefits/) for more information ordownload the 2021 Employee Benefits Guide (https://ncstoragemlbillings.blob.core.windows.net/public/2021%20Billings%20Clinic%20Staff%20Benefits%20Guide.pdf) .
Clinical Documentation Specialist RN - Inpatient
CLINICAL DOCUMENTATION IMPROVEMENT (Billings Clinic Main Campus)
Employment Status: Full-Time (.75 or greater)
Hours per Pay Period: 1.00 = 80 hours (Non-Exempt)
Starting Wage DOE: 28.88 - 36.11
The Clinical Documentation Specialist - Inpatient will conduct concurrent review of clinical
documentation in the inpatient medical record with the goal to obtain the most accurate and
complete physician documentation that appropriately supports the severity of a patient’s illness,
mortality risk, and proper reimbursement. Responsible to query physicians and other caregivers via
written and/or verbal communications for clarification of clinical documentation. He/she works collaboratively with the coding and compliance departments to ensure appropriate final DRG assignments and CC/MCC capture. In collaboration with the RN CCs team will Provides ongoing education related to documentation requirements and opportunities to all providers requirements and opportunities to all providers. Will conduct concurrent and retrospective medical record review for defined patient populations to identify opportunities to improve accuracy of practitioner documentation.
Essential Job Functions
• Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of
• Meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental, and outside agency
• Performs admission reviews within 24 to 48 hours for patient populations to facilitate
• Conducts ongoing reviews of physician/provider and other clinical documentation, lab results,
• Queries physicians and non-physician providers verbally and in writing daily according to
• Validates that follow-through of accurate documentation has occurred and reports appropriately.
• In collaboration with physicians and coding specialists, identifies and records principal diagnosis,
• Provides education to physicians in a one to one setting regarding documentation specificity and the
• Utilizes medical staff established criteria for complications to assist in appropriate documentation
• Collaborates with clinical coordinator and RN CCS with the coding staff and provides clinical
• Acts as a liaison between coding staff and physicians to resolve questions about documentation and/or coding.
• Reviews previous Billings Clinic encounters and supporting information in the concurrent electronic
• Ensures appropriate documentation exists for any conditions that were present on admission (POA).
• Participates in process improvement activities with department leadership, department team members, and inter-departmental team members.
• Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements.
• Maintains competency in all organizational, departmental, and outside agency environmental, employee, or p patient safety standards relevant to job performance.
• Performs other duties as assigned or needed to meet the needs of the department/organization
Knowledge, Skills, and Abilities
• Demonstrates knowledge of compliant query guidelines to obtain appropriate clarity and specificity of documented diagnoses and medical conditions in the medical record.
• Fully understands coding compliance regulations and implications to Billings Clinic
• Interpersonal skills which enable the incumbent to respond to a variety of complex inquiries and requests from payers and physicians
• Ability to deal with difficult situations in a mature and professional manner. Interpersonal skills to assist with training and to respond to questions and assist with problem resolution coders and other team members
• ICD-10-CM,ICD-10-PCS, HCPCS, DRG and CPT-4 coding practices
• Third party and government reimbursement methodologies
• Knowledge of care delivery documentation systems and related medical record documents
• Group dynamics and organizational change
• Customer service techniques and Personal Service Excellence (PSE)
• Professional communication skills, both verbal and written
• Critical thinking skills
• Microsoft Office programs (i.e., Word, Excel, PowerPoint, Access)
• Operation of personal computer and peripherals
• Data gathering, analysis, trending and results reporting; developing recommendations for action based on information
• Developing and maintaining databases
• Developing and presenting information to diverse audience groups
• Conflict resolution and problem solving skills
• Process improvement skills
• Leadership skills necessary to facilitate change in clinical documentation quality and accuracy
• Interpreting and applying guidelines and procedures
• Incorporate population specific needs into all aspects of communication and documentation/clinical indicator review; scope of services provided will encompass age groups from infant through geriatric
• Communicate clearly and effectively, both verbally and in writing
• Establish and maintain collaborative relationships
• Work independently
• Perform appropriate procedures requiring manual and finger dexterity, write legibly, and manipulate a computer
• Have adequate visual acuity required to read, interpret and transcribe written material and to perform appropriate procedures
• Have adequate hearing and verbal communication skills to perform procedures and interact with patients, families, and other health care providers
• Perform duties with frequent interruptions and competing priorities
• Work on multiple projects simultaneously
• Acts independently with minimal supervision
• Ability to define and implement an evolving documentation, coding, and reimbursement program in a complex, integrated health care system
• Requires frequent interaction with medical staff, management, employees, and external organizations
• Must be able to work closely with a variety of diverse and complex issues and both internal and external health care providers
• Graduate of an approved school of nursing, Bachelor’s degree preferred
• Three (3) years of medical/surgical nursing experience with at least one year of Billings Clinic experience preferred but not required.
Certifications and Licenses
• Current Montana license as an RN at hire
• Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC), or Certified Coding Specialist (CCS) preferred, or ability to obtain at least one certification within two years.
Billings Clinic is Montana’s largest health system serving Montana, Wyoming and the western Dakotas. A not-for-profit organization led by a physician CEO, the health system is governed by a board of community members, nurses and physicians. Billings Clinic includes an integrated multi-specialty group practice, tertiary care hospital and trauma center, based in Billings, Montana. Learn more atwww.billingsclinic.com/aboutus (https://www.billingsclinic.com/about-us/)
Billings Clinic is committed to the principles of Equal Employment Opportunity. All policies and processes are designed toward achieving fair and equitable treatment of all employees and job applicants. Employees are encouraged to discuss any concerns they have in this regard with their immediate supervisor and/or the Vice President People Resources. All employees and job applicants will be provided the same treatment in all aspects of the employment relationship, regardless of race, color, creed, religion, national origin, gender, gender identity, sexual orientation, age, marital status, genetic information or disability.