Clinical Documentation Specialist
Saint Joseph Mercy Health System

Pontiac, Michigan

Posted in Medical and Nursing


This job has expired.

Job Info


Employment Type:
Full time
Shift:
Day Shift

Description:

ESSENTIAL FUNCTIONS

Knows, understands, incorporates, and demonstrates the Trinity Health 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 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. Accurately 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. Proficient with leveraging 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.

MINIMUM QUALIFICATIONS

  • Must possess an Associate/Diploma Degree in Nursing, or an Associate Degree in Health Information Technology (HIT).
  • Current Registered Nurse License in the State of practice, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or Certified Coding Specialist (CCS) required. Certified Clinical Documentation Specialist (CCDS) preferred.
  • Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing 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.
  • Accurate 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.
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.


This job has expired.

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