RN Clinical Documentation Specialist - ST Peters Hospital

Overview

• Recognized leader:
  Magnet Hospital in the Capital Region
• Quality of Life:
  Where career opportunities and quality of life converge
• Advancement:
  Strong orientation program, generous tuition allowance and career development

Full time

Day Shift

RN Clinical Documentation Specialist — Full-time day shift — St. Peter's Hospital in Albany, NY

• Recognized leader:
  Magnet Hospital in the Capital Region
• Quality of Life:
  Where career opportunities and quality of life converge
• Advancement:
  Strong orientation program, generous tuition allowance and career development

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 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.

• Know, understand, incorporate, and demonstrate the Trinity Health Mission, Vision, and Values in behaviors, practices, standards, policies, procedures and decisions.
• Demonstrate understanding of appropriate clinical documentation to ensure severity of illness, risk of mortality and level of services provided are accurately reflected in the health record.
• Assist in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes.
• Serve as a resource for appropriate clinical documentation; communicate with and educate physicians and all healthcare team members regarding clinical documentation and monitor provider engagement.
• Identify learning opportunities for healthcare providers.
• Conduct concurrent reviews of selected patient health records addressing legibility, clarity, completeness, consistency and precision of clinical documentation.
• Formulate compliant clarifications/queries following Trinity Health’s documentation integrity procedures.
• Interact with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification/query requests and educational opportunities.
• Accurately code relevant, appropriate and compliant working diagnoses codes, establishing a working principal diagnosis and working DRG (MS or APR).
• Collaborate with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care.
• Resolve all discrepancies in a courteous manner.
• Demonstrate problem-solving skills based on theoretical knowledge, clinical experience and sound judgement; serve as a professional role model with desirable practice behaviors.
• Proficient with leveraging the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness.
• Perform other duties as assigned by leadership.
• Maintain 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, and other policies and procedures to ensure ethical and professional behavior.

Must possess an 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.

Must Possess One Of The Below

• Current Registered Nurse License
• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)
• Certified Coding Specialist (CCS) required
• 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…