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Clinical Documentation Specialist - REMOTE

Company: Trinity Health
Location: Mishawaka
Posted on: January 17, 2022

Job Description:

Employment Type:Full timeShift:Day Shift Description: JOB SUMMARY Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement of clinical documentation through the roles of educator and consultant. Facilitates improvement in the overall quality completeness and accuracy of medical record documentation through extensive record review. Through extensive interaction with coders, physicians and other members of the healthcare team, achieve appropriate clinical documentation to support the medical necessity and level of services rendered to all patience. Participates in the development and delivery of education for providers and members of the health care team. JOB DUTIES 1. Actively demonstrates the organization's mission and core values, and conducts oneself at all times in a manner consistent with these values. 2. Knows and adheres to all laws and regulations pertaining to patient health, safety and medical information. Demonstrates behaviors consistent with identified competencies and job requirements 3. Interacts collaboratively with medical staff, nursing staff, coding staff, case managers, and other patient care providers to improve the quality of chart documentation to accurately reflect level of services provided. 4. Performs initial case reviews and appropriate follow-up reviews based on judgment of clinical picture. 5. Performs concurrent review of all components of the medical records of specified patient population to include assignment of DRG, identifying complications and co morbid conditions, and specific co-existing conditions. 6. Documents findings in appropriate format based on need to communicate the information to the medical staff or coding. The format may include any or all of the following: DRG worksheets, Occurrence Reporting System focus study entries, coding and reimbursement preliminary attestation sheets and queries. 7. Accurately interprets clinical information in the medical record including diagnostic tests, medications, procedures, and nursing assessments. 8. Assists in the research and development of evidence-based physician order sets and protocols. 9. Proficient in accessing multiple software systems and integrating data from all systems including Occurrence Reporting System application, Electronic Medical Record, and the Coding and Reimbursement software. 10. Performs other duties consistent with purpose of job as directed. JOB SPECIFICATIONS AND CORE COMPETENCIES Education: Graduate of an accredited RN program. Bachelor's Degree in Nursing strongly preferred. Licensure: RN Indiana license. Certifications (preferred): CCDS and CCS Experience: 5 plus years of experience in an acute care setting is required. Other Job Requirements: Competent in utilizing multiple software systems. Ability to maintain accurate, detailed, organized records is essential as is the ability to communicate effectively both in writing and orally. Must maintain strict confidentiality of all patient and physician information. Working knowledge of medical terminology and coding processes including DRG and ICD-10. Knowledge of elements of disease processes and related procedures. Thorough up-to-date clinical skills with knowledge of pathology, pharmacology, surgical procedures, etc. Demonstrates organizational and critical thinking skills. Computer literacy in word processing and spreadsheet population and analysis. Experience in working directly with physicians including excellent communication skills with the ability to define physician perceptions and concerns. Assigned hours within your shift, starting time, or days of work are subject to change based on departmental and/or organizational needs. Trinity Health's Commitment to Diversity and Inclusion Trinity Health employs about 133,000 colleagues at dozens of hospitals and hundreds of health centers in 22 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.Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.

Keywords: Trinity Health, Mishawaka , Clinical Documentation Specialist - REMOTE, Healthcare , Mishawaka, Indiana

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