Job Description

**Responsibilities** The Clinical RN Document Improvement Specialist - (CDS) is responsible for providing Clinical Documentation Improvement (CDI) program oversight related to the concurrent review of the clinical documentation in the inpatient medical record. The goal of the CDS practice is to assess the technical accuracy, specificity, and completeness of provider clinical documentation, and to ensure that the documentation explicitly identifies all clinical findings and conditions present at the time of service. This position collaborates with providers and other healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely the clinical treatment, decisions, and diagnoses for the patient. The CDS uses clinical expertise and clinical documentation improvement practices and facility specific tools for best practice and compliance with the mission / philosophy, standards, goals and core values of Dignity Health. The Clinical Documentation Specialist utilizes coding and nursing clinical expertise to identify opportunities and ensure accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes. This position does not have patient care duties, does not have direct patient interactions, and has no role relative to patient care. \#RN@DH **Qualifications** Minimum Required: + 2+ years experience in Clinical Documentation Improvement (CDI) + 3+ years acute care experience. + Experience communicating and working closely with physicians. + Basic proficiency using a PC in a Windows environment, including Microsoft Word, Excel and Electronic Medical Records (Cerner is preferred) + Excellent verbal and written skills including strong organizational skills. + Current CA RN license Preferred/Desired: + Previous or current Case Management experience and/ or critical care experience + Current certification as a CCDS, CDIP or CCS + A combination of education and experience, which provides the above knowledge, skills and abilities, will be considered + Certified Clinical Documentation Specialist (CCDS), Basic Coding and DRG education/training + Bachelor of Sciences degree in a health related field **Overview** **About Us** Dominican Hospital (a member of Dignity Health) is a 222-bed facility that offers a wide range of services to residents of California's Central Coast. With 24/7 emergency care, comprehensive care in cardiac, orthopedics, oncology, women's and children's services, we continue to lead the region in medical innovation and excellence in healthcare. **Comprehensive Care** Dominican offers emergency services and is a Certified Stroke Center and Chest Pain Center. Dominican's services include the only comprehensive Cancer Center in Santa Cruz County, a Total Joint Replacement program, and advanced neurological and endoscopic services. Dominican regularly receives 'A' grades for hospital safety from Leapfrog Group, and has received national recognition for superior patient safety, cardiac care, and stroke treatment from Healthgrades, a leading provider of comprehensive information about physicians and hospitals. As Santa Cruz County's heart attack (STEMI) receiving center, Dominican Hospital provides cutting edge cardiac care. The hospital's heart attack treatment times consistently beat the national average, and the hospital offers two cardiac catheterization labs available 24 hours a day, 7 days a week. Groundbreaking cardiac procedures at Dominican include the Transcatheter Aortic Valve Replacement (TAVR) procedure, which allows for heart valve replacement without opening a patient's chest. Dominican Hospital has forged significant partnerships with area hospitals to bring exceptional care to Santa Cruz County. The hospital offers a level III Neonatal Intensive Care Unit (NICU) through a partnership with Lucile Packard Children's Hospital Stanford. Neurosurgery at Dominican is also offered through a partnership with Stanford Health Care. **In The Community** Beyond care inside the hospital, Dominican is dedicated to the health and wellness of the Santa Cruz community. Community programs include a Mobile Wellness Clinic, a tattoo removal program, and support groups for patients and new mothers. In addition, and in accordance with our mission, Dominican Hospital supports programs for the underserved in our community, including children and adults, students, seniors, and the homeless population. Dominican also has received several awards for environmental excellence. **Pay Range** $82.58 - $105.66 /hour We are an equal opportunity/affirmative action employer.

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