Clinical Documentation Specialist - St. Ann's

Employment Type:

Full time

Shift:

Description:

At Mount Carmel, we’re committed to making a meaningful difference in the lives of our patients and communities. Our colleagues – people like you – share our passion for always going above and beyond to provide the highest standards of care.

The Clinical Documentation Specialists will concurrently review medical records and assist physicians in removing the barriers between clinical and coding languages to allow more specific and complete documentation.

Through interaction with the physicians and other members of the healthcare team, facilitates improvement in quality, completeness and accuracy of the medical record documentation to support severity of illness, medical necessity and level of services rendered.

Responsibilities

• Provides nursing care, ensures an environment of patient safety, promotes evidence-based practice and quality initiatives and exhibits professionalism in nursing practice within the model of the ANCC Magnet Recognition Program®.
• 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.
• Conduct 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.
• Responsible for compliance with Organizational Integrity through raising questions and promptly reporting actual or potential wrongdoing.

Requirements

• 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

• Preferred certification or licensure includes:

  a. Current Registered Nurse License,

  b. Registered Health Information Administrator (RHIA),

  c. Registered Health Information Technician (RHIT),

  d. Certified Coding Specialist (CCS),

  e. Certified Clinical Documentation Specialist (CCDS)

  f. Certified Documentation Improvement Professional (CDIP).

  3. 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.

Discovering opportunities, support and excellence – all while making a real difference in patients’ lives – begins at Mount Carmel. Find a new beginning and advance your career with us.

Mount Carmel and all its affiliates are proud to be equal opportunity employers. We do not discriminate on the basis of race, gender, religion, sexual orientation or physical ability.

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Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. 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.