Top 36 Clinical documentation specialist Jobs in Tucson, Az

Registered Nurse Clinical Documentation Integrity Specialist - Inpatient
Tucson Medical Center —Tucson, AZ
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Utilization Review Specialist
El Dorado Springs —Tucson, AZ
- Overtime
- CPR Certification
- Psychiatry
- Mid-level
- Disability insurance
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HIM Coder III - Remote
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- 5 years
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RN - Behavioral Health
Americas Rehab Campuses —Tucson, AZ
- $38 - $42 an hour
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- Background check
- Current TB test
- Patient monitoring
- Health insurance
- Dental insurance
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Per Diem Clinical Research Nurse - Home Visits
Science 37 —Tucson, AZ
- $50 - $55 an hour
- Nights as needed
- Nursing
- RN License
- BLS Certification
Revenue Cycle Float Pool Specialist
Tucson Medical Center —Tucson, AZ
- Full-time
- Float pool
- HIPAA
- Mid-level
9d
Data and Research Coordinator
Liver Institute PLLC —Tucson, AZ
- From $16 an hour
- Part-time
- Microsoft PowerPoint
- Microsoft Word
- Microsoft Excel
Quick Apply
Registered Nurse - Clinical Decision Unit
Tucson Medical Center —Tucson, AZ
- Full-time
- Nursing
- RN License
- Hospital
Registered Nurse - Med Surg Clinical Decision Unit
Tucson Medical Center —Tucson, AZ
- Full-time
- Nursing
- RN License
- Hospital
Registered Nurse RN Behavioral Health Geriatric Psych
Banner Health —Tucson, AZ
- 12 hour shift
- Nursing
- RN License
- BLS Certification
- Health insurance
11d
Registered Nurse Pre OP (Main)
Tucson Medical Center —Tucson, AZ
- Full-time
- Nursing
- RN License
- Hospital
2d
Registered Nurse_ PRN Pre Op
Tucson Medical Center —Tucson, AZ
- Per diem
- Nursing
- RN License
- Hospital
3d
Home Infusion Registered Nurse (RN)
Enliven Home Infusion Specialists Arizona —Tucson, AZ
- $50 an hour
- Per diem
- Background check
- CPR Certification
- Nursing
- Travel reimbursement
- Flexible schedule
Quick Apply
Registered Nurse (RN) - Special Procedures Area
Carondelet St. Marys Hospital —Tucson, AZ
- PRN
- Nursing
- RN License
- PALS Certification
Registered Nurse (RN) -OR Open Heart
Carondelet St. Marys Hospital —Tucson, AZ
- Full-time
- Nursing
- RN License
- PALS Certification
Registered Nurse (RN) - Neuro Tele
Carondelet St. Josephs Hospital —Tucson, AZ
- Part-time
- Nursing
- RN License
- PALS Certification
Registered Nurse RN Neonatal ICU NICU
Banner Health —Tucson, AZ
- Full-time
- Nursing
- Surgery
- RN License
- Health insurance
9d
Staff RN - ECMO Spec / FT, D/N
Children's Nebraska —United States
- Overtime
- Nursing
- RN License
- BLS Certification
- Flexible schedule
Staff RN - ECMO Spec / FT, nights
Children's Nebraska —United States
- Overtime
- Nursing
- RN License
- BLS Certification
- Flexible schedule
Travel IMC RN Job in Birmingham, Alabama
GIFTED Healthcare —United States
- $2,122.06 - $2,242.62 a week
- Overtime
- Nursing
- Medication administration
- RN License
- Health insurance
- Dental insurance
Quick Apply

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Registered Nurse Clinical Documentation Integrity Specialist - Inpatient

Tucson Medical Center -
Tucson, AZ

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Job Details

Full-time

Qualifications

Inpatient experience
RN License
Employee relationship building
Acute care experience
Stakeholder relationship building

Full Job Description

SUMMARY:

Provides concurrent review of the clinical documentation in the medical record; review the medical record with a clinical lens to identify any missing or understated diagnoses. Queries the medical staff when necessary, by written and/or verbal communication to obtain accurate and complete physician documentation that supports the patient condition(s) and treatment plan. Performs a thorough chart review to determine the appropriate principal diagnosis of the patient. Coordinates with coding/HIM/UR and other departments to achieve a record that reflects the acuity of the patient and level of care provided.

ESSENTIAL FUNCTIONS:

Conducts initial and follow-up concurrent reviews on inpatient admissions for opportunities to clarify documentation in the medical record for accurate reflection of the acuity of the patient and justifying the level of care. Documents findings in workflow tools, noting all key information used in the tracking process. Review medical record concurrently for documentation not yet in the record but supported by clinical indicators.
Uses relationship building and strong communication skills to develop a rapport with providers to clarify information in the medical record. Uses appropriate querying templates to get needed documentation. Conducts follow-up on unanswered queries during the patient stay to obtain a response to unanswered queries.
Provides education to physicians on the importance of complete documentation and key documentation concepts during regular physician meetings or on individually with physicians.
Use data provided by managers, directors, and consulting team to actions to identify what is working well and areas of focus.
Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication.
Adheres to TMC organizational and department-specific safety, confidentiality, values, policies and standards.
Performs related duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION: Graduation from a qualified, nationally-accredited nursing program.

EXPERIENCE: Three (3) years of RN clinical experience in an acute care setting. CDI experience preferred.

LICENSURE OR CERTIFICATION: Current RN licensure permitting work in state of Arizona. CCDS (Certified Clinical Documentation Specialist) from ACDIS or CDIP (Certified Documentation Improvement Practitioner) from AHIMA preferred.

KNOWLEDGE, SKILLS AND ABILITIES:

Extensive clinical knowledge and understanding of pathology/physiology; best demonstrated by clinical experience in hospital setting.
Strong critical thinking skills and the ability to review the medical record to identify information not yet documented but supported by clinical indicators or clinical clues.
Knowledge of age-specific patient needs and the elements of disease processes and related procedures.
Excellent written and verbal communication skills; ability to write concisely and effectively when communicating with providers.
Assertive personality traits to facilitate ongoing physician communication.
Working knowledge of inpatient admission criteria.
Ability to work independently in a time-oriented environment.
Ability to stand and walk in the performance of job responsibilities.
Demonstrates knowledge of the importance of, and makes an effort to capture, all appropriate secondary diagnoses for quality rating purposes.

Apply Now

Refine Your Search

clinical documentation specialist jobs in tucson, az

Registered Nurse Clinical Documentation Integrity Specialist - Inpatient

Utilization Review Specialist

HIM Coder III - Remote

RN - Behavioral Health

Per Diem Clinical Research Nurse - Home Visits

Revenue Cycle Float Pool Specialist

Data and Research Coordinator

Registered Nurse - Clinical Decision Unit

Registered Nurse - Med Surg Clinical Decision Unit

Registered Nurse RN Behavioral Health Geriatric Psych

Registered Nurse Pre OP (Main)

Registered Nurse_ PRN Pre Op

Home Infusion Registered Nurse (RN)

Registered Nurse (RN) - Special Procedures Area

Registered Nurse (RN) -OR Open Heart

Registered Nurse (RN) - Neuro Tele

Registered Nurse RN Neonatal ICU NICU

Staff RN - ECMO Spec / FT, D/N

Staff RN - ECMO Spec / FT, nights

Travel IMC RN Job in Birmingham, Alabama

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