Clinical Documentation Specialist - Remote

Employment Type: Full time

Shift: Day Shift

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.

• 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.

• 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.

Education: Associate/Diploma Degree in Nursing and five - ten years acute care medical or surgical experience required. Bachelor of Science in Nursing preferred. A degree in Health Information Management with credentials of RHIA, RHIT, or CCS with extensive clinical knowledge and a minimum of 5 years inpatient coding experience will be considered in lieu of a RN.

Licensure/Certification: Current license to practice as registered nurse in the State of Ohio. Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Coding Specialist (CCS) will be considered in lieu of a RN.

Experience: Minimum of 5 years acute care medical or surgical experience required; utilization/Case Management,…