Job Description

Clinical Documentation Specialist

At MercyOne, health care is more than just a doctor's visit or a place to go when you're in need of medical attention. Our Mission is based on improving the health of our communities that means not only when you are sick but keeping you well. MercyOne Dubuque Medical Center is a 25-bed critical access hospital, which provides a vital lifesaving link to rural communities in Clayton County and surrounding areas through ambulance and emergency services. MercyOne is committed to providing quality, personalized and safe health care close to home. The emergency department is staffed 24 hours a day, seven days a week with board certified physicians and advanced level practitioners who are well-trained to treat emergency needs. MercyOne Dubuque Medical Center is certified as a Level IV Trauma Center by the Iowa Department of Public Health.

Join the MercyOne Family! We are looking to hire a Clinical Documentation Specialist.

As a Clinical Documentation Specialist at MercyOne, you will utilize 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.

Schedule:

• Full time 40 hours a week
• Days
• Remote

General Requirements:

• Knows, understands, incorporates, and demonstrates the Trinity Health/ Mercy One 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, 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 principal 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.
• 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 to ensure adherence in a manner that reflects honest, ethical and professional behavior.

Education:

• 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: 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), 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.
• 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.

Colleagues of MercyOne Health System enjoy competitive compensation with a full benefits package and opportunity for growth throughout the system!

Visit MercyOne Careers to learn more about the benefits, culture, and career development opportunities available to you at MercyOne Health System circle of care.

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.

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