Clinical Documentation Specialist

Welcome to Sutter Health, where we are committed to providing exceptional care to our patients every day. As a Clinical Documentation Specialist, you will play a crucial role in ensuring the accuracy and completeness of our medical records, which directly impacts the quality of care we provide. We are looking for a detail-oriented and highly organized individual who is passionate about healthcare and has a strong understanding of clinical documentation processes. If you possess excellent communication skills and have a background in healthcare, we invite you to join our team and make a difference in the lives of our patients.

1. Review and analyze medical records to ensure accuracy and completeness of clinical documentation.
2. Collaborate with healthcare providers to identify and clarify incomplete or unclear documentation.
3. Utilize coding and classification systems to accurately assign diagnoses and procedures.
4. Stay up-to-date on industry standards and regulations related to clinical documentation.
5. Communicate with coding and billing teams to ensure accurate coding and billing based on clinical documentation.
6. Educate healthcare providers on the importance of accurate and complete clinical documentation.
7. Identify and report any patterns or trends in documentation discrepancies to improve overall quality and compliance.
8. Conduct audits and provide feedback to healthcare providers to improve documentation practices.
9. Maintain confidentiality and adhere to HIPAA regulations when handling sensitive patient information.
10. Participate in departmental and organizational meetings and trainings as required.
11. Utilize electronic health record systems and other technology to efficiently manage and track documentation tasks.
12. Collaborate with other members of the healthcare team to provide comprehensive and coordinated care for patients.
13. Assist in developing and implementing policies and procedures related to clinical documentation.
14. Maintain accurate and organized records of all documentation activities.
15. Continuously seek opportunities to improve documentation processes and contribute to the overall improvement of patient care.

According to JobzMall, the average salary range for a Clinical Documentation Specialist in San Francisco, CA, USA is $85,000 to $115,000 per year. This range can vary depending on experience, education, and the specific company or organization the individual is working for. With additional certifications and experience, the salary range may increase.

Sutter Health is a not-for-profit integrated health delivery system headquartered in Sacramento, California. It operates 24 acute care hospitals and over 200 clinics in Northern California. Sutter Hospital Association was founded in 1921 as a response to the 1918 flu pandemic.