Clinical Documentation Specialist

: Employment Type: Part time Shift: Day Shift Description: At MercyOne, health care is more than just a doctor's visit or a place to go when you're in need of medical attention. Our Mission is based on improving the health of our communities - that means not only when you are sick but keeping you well. MercyOne Clinton Medical Center is a Catholic, not-for-profit, full-service community health system serving counties in eastern Iowa and western Illinois. With approximately 50,000 patient admissions every year, MercyOne Clinton operates 249 licensed beds. In addition to a wide range of traditional hospital services, MercyOne Clinton provides a continuum of care with specialized services in wound care, radiation oncology, dialysis, imaging, sleep disorders, therapy services, and skilled care. MercyOne Clinton has a staff of more than 800 employees, making it one of the community's largest employers.

Want to learn more about MercyOne Clinton? Click here: Find a Location Clinton, Iowa (IA), MercyOne Clinton

Join the MercyOne Family! We are looking to hire a Clinical Documentation Specialist

As a Clinical Documentation Specialist at MercyOne, you will utilize 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.

Schedule:

• Part time 20 hours a Week
• Day shift
• Remote

General Requirements:

• Knows, understands, incorporates, and demonstrates the Trinity Health/ Mercy One 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.

• 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.

• Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgement and serves as a professional role model by demonstrating desirable practice behaviors.

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

• Performs other duties as assigned by leadership.

• Maintains a working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health's Organizational Integrity Program, Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

Education:

• 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.

• 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).

• 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.

• 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.

• 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.

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

• Must be comfortable operating independently and in a collaborative environment.

• Must possess a personal presence that is characterized by a sense of honesty, integrity and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals and values of Trinity Health.

Colleagues of MercyOne Health System enjoy competitive compensation with a full benefits package and opportunity for growth throughout the system!

Visit MercyOne Careers to learn more about the benefits, culture, and career development opportunities available to you at MercyOne Health System circle of care.

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.