Clinical Documentation Specialist-RN

St. Luke's Health - Patients Medical Center provides inpatient and outpatient medical and surgical services to residents of Pasadena, Deer Park, La Porte, Baytown, and Clear Lake. The facility includes 53 medical/surgical beds, eight ICU beds and three endoscopy rooms, and offers a range of primary and specialized services—wound care, general surgery, gastroenterology, occupational health, heart and vascular, women’s services, diagnostic imaging, outpatient rehab services, and sleep disorders.

As a Clinical Documentation Specialist RN, you will be responsible for facilitating accurate documentation for severity of illness and quality in the medical record. This involves
extensive record review, interaction with physicians, health information management professionals, and nursing staff. Active participation in team meetings and education of staff in the CDMP process is a key role.

Every day, you will leverage your expertise to provide individualized, comprehensive care, making critical assessments, performing skilled procedures, and meticulously implementing patient care plans. You'll collaborate seamlessly within an interdisciplinary team, contributing to a dynamic environment focused on optimal patient outcomes.

To be successful in this position you will:

• Reviews medical record for completeness and accuracy for severity of illness (SOI) and quality using the Compliant Documentation Management Program (CDMP) documentation strategies
• Accurate and timely record review
• Recognize opportunities for documentation improvement
• Formulate clinically credible documentation clarifications
• Request documentation clarifications as appropriate for SOI, Core Measures, and Patient Safety

Job Requirements
We are looking for a responsible and compassionate Registered Nurse with top-notch clinical skills, a caring attitude, and the ability to work independently with minimal supervision. It is also important to display excellent verbal and written communication and interpersonal skills as well as the ability to effectively educate patients and their families on the in-home healthcare process.

• Current Registered Nurse (RN) license that allows you to practice in our state
• Graduate of an accredited nursing program
• Five (5) years of adult acute care experience in med/surg, critical care, emergency room, or PACU
• High school diploma or GED