Clinical Documentation Specialist, REMOTE

Full time, Monday through Friday day shift position based at St. Mary's Sacred Heart Hospital in Lavonia, Georgia.

About the Role

The 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 interaction with physicians and other healthcare team members, ensures appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality, and level of services rendered. Participates in the development and delivery of education for providers and healthcare team members.

Responsibilities

• Understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.
• Demonstrates understanding of appropriate clinical documentation to ensure severity of illness, risk of mortality, and level of services 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 comorbidities reflects 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 judgment.
• 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, and Trinity Health’s policies to ensure adherence in a manner reflecting honest, ethical, and professional behavior.

Requirements

• Associate/Diploma Degree in Nursing or Health Information Technology (HIT), or an Advanced degree in nursing or medical field such as NP/APN or PA.
• One of the following credentials:
  • Current Registered Nurse License in the State of practice,
  • Registered Health Information Administrator (RHIA),
  • Registered Health Information Technician (RHIT),
  • Certified Coding Specialist (CCS),
  • Licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN), or
  • Completion of medical school.
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
• Two (2) years of 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.
• 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 email, internet, and computer navigation.
• Ability to use other software as required to perform essential job functions.
• Experience with databases, spreadsheet software, and presentation software preferred.
• Accurate data entry skills and typing skills at a minimum of 30 wpm.
• Comfortable operating independently and in a collaborative environment.
• Personal presence characterized by honesty, integrity, and caring with the ability to inspire and motivate others.