Clinical Documentation Specialist
Clinical Documentation Specialist
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Job Description
Employment Type:
Full timeShift:
Day ShiftDescription:
At MercyOne health care is more than just a doctors visit or a place to go when youre in need of medical attention. Our Mission is based on improving the health of our communities that means not only when you are sick but keeping you well.MercyOne North Iowa is the largest provider of health care services in our region and we are proudly the largest employer in Cerro Gordo County. Our hospital is a private not-for-profit health care center licensed for 346 beds which serves more than 400000 inpatients and outpatients each year. In addition MercyOne North Iowa is a teaching institution. We conduct a Family Medicine Residency Internal Medicine Residency Cardiology Fellowship Hospice and Palliative Medicine Fellowship PGY1 Pharmacy Residency and a School of Radiologic Technology. MercyOne North Iowa is a clinical training site for approximately 500 students from 127 different colleges enrolled in programs for medical laboratory nursing paramedic rehabilitation medical assistants pastoral services physicians and many other medical fields.
Want to learn more about MercyOne North Click here: MercyOne North Iowa Medical Center
Join the MercyOne Family! We are looking to hire a Clinical Documentation Specialist
As a Clinical Documentation Specialist at MercyOne you will utilize advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer educator and consultant. Facilitates the overall quality completeness accuracy and integrity of medical record documentation through extensive record review.
Through extensive interaction with physicians and other members of the healthcare team achieves appropriate clinical documentation to support code assignment medical necessity severity of illness risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.
Schedule:
- Full time 40 hours a week
General Requirements:
- Knows understands incorporates and demonstrates the Mercy One Mission Vision and Values in behaviors practices standards policies procedures and decisions.
- Demonstrates understanding of appropriate clinical documentation to ensure that the severity of illness risk of mortality quality indicators and level of services provided are accurately reflected in the health record. Assists in overall quality timeliness and completeness of the health record to ensure appropriate data provider communication and quality outcomes. Serves as a resource for appropriate clinical documentation.
- Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement. Identifies learning opportunities for healthcare providers.
- Conducts concurrent reviews of selected patient health records to address legibility clarity completeness consistency and precision of clinical documentation.
- Formulates compliant clarifications/queries following Trinity Healths documentation integrity procedures.
- Interacts with physicians nurses and ancillary staff regarding compliant documentation requirements clarification/query requests and educational opportunities.
- Codes all relevant appropriate and compliant working diagnoses codes establishing a working principle diagnosis and working DRG (MS or APR).
- Collaborates with coding staff to ensure documentation of discharge diagnoses and co1morbidities are a complete reflection of the patients clinical status and care. Resolves all discrepancies in a courteous manner.
- Demonstrates expertise in problem-solving skills based on theoretical knowledge clinical experience and sound judgement and serves as a professional role model by demonstrating desirable practice behaviors.
- Leverages the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness.
- Performs other duties as assigned by leadership.
- Maintains a working knowledge of applicable Federal State and local laws and regulations accrediting agencies Trinity Healths Organizational Integrity Program Standards of Conduct Code of Ethics as well as other policies and procedures in order to ensure adherence in a manner that reflects honest ethical and professional behavior.
Education:
- Must possess an Associate/Diploma Degree in Nursing or Health Information Technology (HIT) or an Advanced degree in nursing or medical field such as MD DO NP/APN or PA. In the absence of a college degree must have 3 or more years experience as an inpatient coder or clinical documentation specialist.
- Preferred certification or licensure includes:
- Current Registered Nurse License
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- Certified Coding Specialist (CCS)
- Certified Clinical Documentation Specialist (CCDS)
- Certified Documentation Improvement Professional (CDIP).
- Experience in Critical Care Medical or Surgical Inpatient Care Nursing as an RN physician assistant (PA) nurse practitioner/advanced practice nurse (NP/APN) medical school graduate or as an inpatient coder preferred.
- Excellent communication (verbal and written) interpersonal collaboration and relationship1building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team.
- Demonstrated ability to use a standard desktop and Windows based computer system including a basic understanding of email internet and computer navigation. Ability to use other software as required to perform the essential functions on the job. Experience with databases spreadsheet software and presentation software preferred.
- Data entry skills and typing skills at minimum 30 wpm
Colleagues of MercyOne Health System enjoy competitive compensation with a full benefits package and opportunity for growth throughout the system!
Our Commitment
Rooted in our Mission and Core Values we honor the dignity of every person and recognize the unique perspectives experiences and talents each colleague brings. By finding common ground and embracing our differences we grow stronger together and deliver more compassionate person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin disability veteran status or any other status protected by federal state or local law.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
