Clinical Documentation Specialist

4 weeks ago

Mason City, United States Trinity Health 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.

**What you will Do:**

+ Knows, understands, incorporates, and demonstrates the Trinity Health 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 Health's documentation integrity procedures.

**Hours/Schedule:**

Full Time; Day Shift

**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).

**Position Highlights and Benefits:**

· 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.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran

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