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Providence Health & Services Clinical Documentation Specialist in Portland, Oregon


Providence is calling a Clinical Documentation Specialist (0.0 FTE, Days) to Providence Groth Building in Portland, OR.

We are seeking a Clinical Documentation Specialist who will be part of a regional team that facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. This requires analysis of clinical information to identify areas within the medical record for potential gaps in physician documentation.

This position assists with necessary modification to clinical documentation through extensive interaction with physicians. It requires work with coding staff to assure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care.

This position develops and implements plans for education of physicians, nursing and ancillary staff on documentation improvement.

In this position you will:

  • Applies concepts of the nursing process, such as identification of disease, facilitation of healing, health promotion, illness prevention and patient care delivery to each task, clinical review and or quality improvement project.

  • Responsible for improving the overall quality and completeness of clinical documentation by performing medical record documentation review for the Oregon Region.

  • On a daily basis reviews 100% of patient medical records, searching medical entries for appropriate documentation.

  • Uses clinical knowledge to collaborate with providers in identifying appropriateness of clinical documentation; identifying potential diagnoses vs. symptomology.

  • Champions and assists providers in choosing correct terminology in medical record documentation for patients' illnesses and disease processes.

  • Works with Health Information Management coding staff to more accurately reflect case mix indices by improving documentation during the patients' stay, which is reflected in the subsequent coding that occurs post discharge.

  • Participates in work group and steering committees to facilitate improved processes in concurrent coding.

  • Demonstrates understanding and utilizes tools, tones and behaviors that promote patient safety in a highly reliable organization.

  • Uses expert clinical knowledge in pathophysiology and disease processes on a daily basis to support the requests for changes in documentation that are reviewed.

  • Uses clinical knowledge to apply Diagnosis Related Group methodology as means for improving revenue capture.

  • Serves as resource and role model in specialty areas.


Required qualifications for this position include:

  • Bachelor's Degree in Nursing.

  • Five (5) years recent acute care experience in adult acute, critical care, or strong medical/surgical setting.

  • Demonstrated clinical experience related to a wide variety of patient populations and care delivery models.

  • Demonstrated experience in communicating effectively, both verbally and in writing, with physicians, nursing, public, and all levels of hospital management.

  • Current, unencumbered Oregon state RN license required.

Preferred qualifications for this position include:

  • Master's Degree in Nursing

About Providence in Oregon

As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.

The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple,

"Providence will provide the best care and service to every person, every time."

Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.

We offer a full comprehensive range of benefits - see our website for details

Our Mission

As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.

About Us

Providence Health & Services is a not-for-profit Catholic network of hospitals, care centers, health plans, physicians, clinics, home health care and services guided by a Mission of caring the Sisters of Providence began over 160 years ago. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.

Schedule: On Call

Shift: Day

Job Category: Case Management

Location: Oregon-Portland

Req ID: 252316