Clinical Documentation Specialist
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Job Description
Clinical Documentation Specialist reviewing inpatient records for accuracy and completeness at MercyOne Genesis. Educating providers and querying documentation to support compliant patient-care coding.
Responsibilities:
- Direct efforts toward the integrity of clinical documentation as reviewer, educator and consultant
- Facilitate the quality, completeness and accuracy of medical record documentation through extensive record review
- Demonstrate appropriate clinical documentation so severity of illness, risk of mortality, quality indicators and level of services are accurately reflected
- Communicate with and educate physicians and healthcare team members on clinical documentation
- Monitor provider engagement
- Conduct concurrent reviews of selected patient health records for legibility, clarity, completeness, consistency and precision
- Formulate compliant clarifications/queries following Trinity Health's documentation integrity procedures
- Incorporate Trinity Mission, Vision and Values into behaviors, practices, standards, policies, procedures and decisions
Requirements:
- Associate/Diploma Degree in Health Information Technology (HIT) or advanced degree in nursing (NP, APN) or Physician Assistant
- In absence of a college degree, three (3) years' experience as an inpatient code or clinical documentation specialist
- Preferred certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP
- Experience in critical care, medical or surgical inpatient care nursing as an RN, PA, NP, APN or inpatient coder preferred
- Excellent communication, interpersonal, collaboration and relationship building skills
- Strong critical thinking skills and ability to integrate knowledge
- Prioritization and organization skills
- Ability to use standardized desktop and Windows-based computer systems
- Data entry and typing skills of at least 30 wpm
Benefits:
- Equal Opportunity Employer commitment
- Person-centered care commitment
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