Clinical Documentation Specialist

Role Overview

• 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.
• Conducts concurrent reviews of selected patient records to address legibility, clarity, completeness, consistency, and precision of clinical documentation.
• 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.

Requirements

• Associate/Diploma Degree in Nursing and five
• ten years acute care medical or surgical experience required.
• Bachelor of Science in Nursing preferred.
• A degree in Health Information Management with credentials of RHIA, RHIT, or CCS with extensive clinical knowledge and a minimum of 5 years inpatient coding experience will be considered in lieu of a RN.
• Current license to practice as registered nurse in the State of Ohio.
• Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Coding Specialist (CCS) will be considered in lieu of a RN.
• Minimum of 5 years acute care medical or surgical experience required;
• Utilization/Case Management, managed care, or Clinical Documentation and experience in ICD-10 coding conventions and DRG methodology preferred.

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.