Employment Type:

Shift:

Description:

Position Purpose:

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.

What You Will Do:

• Exhibits each of the Mount Carmel Service Excellence Behavior Standards holding self and others accountable and role modeling excellence for all to see. For example: demonstrates friendliness and courtesy, effective communication creates a professional environment and provides first class service.
• Meets population specific and all other competencies according to department requirements.
• Promotes a Culture of Safety by adhering to policy, procedures and plans that are in place to prevent workplace injury, violence or adverse outcome to associates and patients.
• Relationship-based Care: Creates a caring and healing environment that keeps the patient and family at the center of care throughout their experience at Mount Carmel following the principles of our interdisciplinary care delivery system.
• (For patient care providers) 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.

Other Job Responsibilities

• Participates in the performance improvement activities. Attends in-service programs and other activities to promote professional growth and enhance knowledge in care documentation requirements.
• Attends and actively participates in staff meetings, participates in committees as requested.
• Responsible for compliance with Organizational Integrity through raising questions and promptly reporting actual or potential wrongdoing.
• All other duties as assigned.

Minimum Qualifications:

• 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.

• Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), Certified Clinical Documentation Specialist (CCDS), Certified Documentation Improvement Professional (CDIP) or Certified Coding Specialist (CCS) will be considered in lieu of a RN.

• 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.

Position Highlights and 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. You deserve to get paid every day!
• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.

Ministry/Facility Information:

Mount Carmel, a member of Trinity Health, has been a transforming healing presence in Central Ohio for over 135 years. Mount Carmel serves over 1.3 million patients each year at our four hospitals, free-standing emergency centers, outpatient facilities, surgery centers, urgent care centers, primary care and specialty care physician offices, community outreach sites and homes across the region. Mount Carmel College of Nursing offers one of Ohio's largest undergraduate, graduate, and doctor of nursing programs. If you’re seeking a rewarding career where your purpose, passion, and desire to make a difference come alive, we invite you to consider joining our team. Here, care is provided by all of us For All of You!

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.