Clinical Documentation Specialist
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Job Description
Clinical Documentation Specialist reviewing inpatient records for MercyOne Genesis healthcare. Ensuring accurate clinical severity, mortality risk, quality indicators, and service-level documentation.
Responsibilities:
- Demonstrate Trinity Mission, Vision and Values in behaviors, practices, standards, policies, procedures and decisions
- Ensure clinical documentation accurately reflects severity of illness, risk of mortality, quality indicators and level of services provided
- 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 documentation integrity procedures
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 coder 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:
- Full-time remote position
- Equal Opportunity Employer
- Consideration 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
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