Clinical Documentation Specialist-Remote

Employment Type: Full time Shift: Day Shift Position Purpose Clinical Documentation Specialist 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 Exhibits each of the Mount Carmel Service Excellence Behavior Standards holding self and others accountable and role modeling excellence for all to see. Meets population specific and all other competencies according to department requirements. Promotes a Culture of Safety by adhering to policy, procedures and plans that are in place to prevent workplace injury, violence or adverse outcome to associates and patients. Creates a caring and healing environment that keeps the patient and family at the center of care throughout their experience at Mount Carmel following the principles of our interdisciplinary care delivery system. Conducts concurrent reviews of selected patient records to address legibility, clarity, completeness, consistency, and precision of clinical documentation. Demonstrates understanding of clinical documentation requirements to ensure that the severity of illness, risk of mortality, and services provided are accurately reflected in the record. Serves as a resource on appropriate clinical documentation. Communicates documentation discrepancies and coding definitions to the physicians both written and verbally as needed to clarify clinical documentation in accordance to query standards and/or policies. Conducts 1:1 educational sessions with physicians and other healthcare team members related to specific documentation requirements. Collaborates with the multi-disciplinary team, including physicians, patient care services, case management, coding specialists and other healthcare disciplines regarding clinical documentation issues. Utilizes computer systems effectively and maintains record of reviews completed, queries completed and outcome of physician response. Other Job Responsibilities Participates in performance improvement activities and attends in-service programs and other activities to promote professional growth and enhance knowledge in care documentation requirements. Attends and actively participates in staff meetings and committees as requested. Responsible for compliance with Organizational Integrity through raising questions and promptly reporting actual or potential wrongdoing. All other duties as assigned. Minimum Qualifications Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) or an Advanced degree in nursing (NP/APN) or Physician Assistant. In the absence of a college degree, must have 3 or more years’ experience as an inpatient coder or clinical documentation specialist. Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Professional (CDIP) or Certified Coding Specialist (CCS) will be considered in lieu of a RN. Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), or as an inpatient coder preferred. Position Highlights and Benefits Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one. Retirement savings account with employer match starting on day one. Generous paid time off programs. Employee recognition programs. Tuition/professional development reimbursement. Relocation assistance (geographic and position restrictions apply). Discounted tuition and enrollment opportunities at the Mount Carmel College of Nursing. Employee Referral Rewards program. Mount Carmel offers DailyPay – if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday. Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups. Equal Opportunity Employer We are 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, veteran status, or any other status protected by federal, state, or local law. EOE including disability/veteran #J-18808-Ljbffr Trinity Health