Clinical Documentation Specialist RN

1 month ago

Merced, United States Common Spirit Full time

Overview

Mercy Medical Center a Dignity Health member has been building a rich history of care in our community for more than 100 years. We have grown from a small one-story wooden structure into a major healthcare provider with a new 186-bed main campus offering the latest in facility design and technology. Mercy also operates Outpatient Centers a Cancer Center and several rural clinics.Wherever you work throughout our system you will find faces of experience with dedication to high quality personalized care. Joining our 1300 employees 230 physicians and many volunteers you can help carry out our commitment to providing our community with the excellence they have come to associate with Mercy Medical Center.

Responsibilities

Position Summary

Under general direction facilitates improvement in the overall quality completeness and accuracy of medical record documentation. Obtains appropriate clinical documentation through extensive interaction with physicians nursing staff other patient caregivers Case Management and Health Information Management coding staff to ensure that the clinical information used in measuring and reporting outcomes is complete and accurate and that reimbursement is received for the level of services rendered to patients with DRG based payers. Educates all members of the patient care team on documentation guidelines on an ongoing basis. Collects and analyzes data to provide reports and make recommendations. Works collaboratively with staff to provide staff support including assistance with problem solving and recommendations for process improvements. Collaborates with other disciplines regarding proposed DRG changes and proposed quality concerns and communicates with the attending physician or medical director regarding these issues to the appropriate performance improvement committee.

#RN@DH

Qualifications

Qualifications Minimum

* Must possess a valid California Registered Nurse license
* Must possess a valid Basic Life Support (BLS) certificate
* Computer competencies: data entry and analysis (Excel or other database software) word processing (MS Word) presentations (PowerPoint)
* Ability to communicate both verbally and in writing to accomplish assigned responsibilities
* Minimum of three years of nursing experience in an acute care facility or two years of nursing experience in an acute care facility with one year of case management and or one year of coding experience

Desired

* Two year prior experience in Clinical Documentation Specialist with Case Management experience
* Baccalaureate degree preferred
* Knowledge of Case Management
* Knowledge of Medicare MS-DRG

Please be advised that this location requires quarterly American Heart Association (AHA) Resuscitation Quality Improvement (RQI) competency certification post-hire. This ongoing competency is required through resources internal to the facility; outside RQI competency resources are not acceptable for CommonSpirit Health compliance requirements.

#RN@DH

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