Clinical Documentation Specialist (RN) Remote

Employment Type:

Full time

Shift:

Day Shift

Description:

Employment Type:

Full Time

Shift:

Day shift, supporting Central Time Zone

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:

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.

Minimum Qualifications:

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.

Position Highlights and Benefits

The tri-state region, referred to as Western Iowa or Siouxland, is highlighted by safe and friendly communities, excellent schools and a mix of peaceful rural areas and vibrant city atmosphere where Iowa, Nebraska and South Dakota meet at the Missouri River.

Situated in the heart of downtown Sioux City, MercyOne Siouxland Medical Center is also well positioned for urban living in any of the newly renovated apartments, downtown lofts, or townhome living options. The downtown also features a historic district with excellent restaurants and social spots, and youll just be steps away from the beautifully renovated Warrior Hotel for dinner and the gorgeous Orpheum Theatre for entertainment.

We care about your well-being, both physical and mental, which is why our benefit package includes:

Wellness programs

Education reimbursement

Personalized health insurance plans including dental and vision

Paid time off

Long- and short-term leave

Retirement planning

Life insurance coverage

Ministry/Facility Information

MercyOne Western Iowa serves the needs of individuals in a 33-county area including western Iowa, eastern Nebraska and southeastern South Dakota. MercyOne Siouxland Medical Center (https://www.mercyone.org/siouxland/location/mercyone-siouxland-medical-center) , a 238-bed regional facility, is home to the only Level II trauma center in the area – one of only four trauma care facilities in the state to receive verification from the American College of Surgeons – and MercyOne Air Med, a regional helicopter ambulance service. Along with a managed hospital Hawarden, Iowa, and a partnership with Dunes Surgical Hospital (https://www.mercyone.org/location/dunes-surgical-hospital) in South Dakota, the region also operates a primary care network, specialty care clinics and home health care, providing an entire continuum of preventative, primary, acute and tertiary health care services to provide personalized, compassionate care for the communities we serve and beyond.

MercyOne Siouxland Medical Center and all its affiliates are proud to be equal opportunity employers. We do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state, or local protected class.

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