Clinical Documentation Specialist

4 weeks ago

Mason City, United States Trinity Health Corporation Full time

Employment Type:

Full time

Shift:

Day Shift

Description:

Position Purpose:

Utilizes 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.

What you will Do:

* Demonstrate 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.


* 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 co-morbidities are a complete reflection of the patient's clinical status and care. Resolves all discrepancies in a courteous manner.


* Leverages the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness.



Hours/Schedule: Full Time, Day Shift (40) hours/week. No weekends or holidays.

Minimum Qualifications:

1. 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.

2. 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).



3. 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.

4. Excellent communication (verbal and written), interpersonal, collaboration and relationship-building 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.

5. 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.

6. Data entry skills and typing skills at minimum 30 wpm.

Position Highlights and Benefits

* MercyOne Nurses Rock Scholarship - loan repayment for ADN or BSN


* Education Assistance offered


* Effective Day 1 Benefit Package (Medical, Dental, Vision, and more) for positions 16 hours per week or greater


* Competitive wages; including weekend and night differentials


* Generous paid time off program


* Retirement Savings program with employer match starting on Day 1



Ministry/Facility Information:

MercyOne North Iowa Medical Center provides expert health care to 15 counties.

MercyOne North Iowa Medical Center is a 342 bed, regional referral teaching hospital in Mason City, Iowa. MercyOne New Hampton Medical Center is an 11 bed, rural access hospital in New Hampton, Iowa. Our service area spans 15 counties across northern Iowa and southern Minnesota. We serve a population over 260,000.

With more than 3,000 colleagues and a medical staff of almost 500 physicians and allied health professionals, MercyOne North Iowa Medical Center is the largest employer in the region.

MercyOne Medical Group - North Iowa is part of Iowa's largest multispecialty clinic systems. In north Iowa, our clinics are made up of more than 25 primary care, pediatric, internal medicine and specialty clinics.

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is 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, status as a protected veteran, or any other status protected by law.

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