1 clinical documentation improvement specialist Job in cincinnati, oh
TriHealth is Hiring a CLINICAL DOCUMENTATION SPECIALIST-REGISTERED NURSE (Days-64 Hours) Near Cincinnati, OH
| Job Overview: Concurrently review inpatient medical records for accuracy and completeness of documentation on admission and throughout hospitalization. Ensure the accuracy and completeness of clinical information within the chart by analyzing for potential gaps in physician documentation through clarifications to improve documentation on principal diagnosis, co-morbidities, present on admission and quality core measures. Facilitate improvement in clinical documentation through education and extensive interaction with physicians, nursing staff and all other members of the health care team. Systematic development and implementation of educational opportunities for physicians, nursing staff and all other members of the health care team. Collaboration with coding staff in assuring complete and compliant documentation in all inpatient charts at time of discharge. Participates in the interdisciplinary process to ensure that selected clinical quality indicators are met. Job Requirements: Bachelor's Degree in Nursing Equivalent experience accepted in lieu of degree Registered Nurse Basic keyboarding and Microsoft office 5-7 years experience Clinical in Nursing Job Responsibilities: Facilitates the accurate representation of the severity of illness on TriHealth hospital records by performing admission/continued stay reviews using Clinical Documentation guidelines and standard performance measures. Processes discharges by updating the Documentation Worksheet to reflect any changes in status, procedures/treatments, and conferring with the physician to finalize diagnoses. Accurately documents data into CDMP Trak. Reviews clinical issues with coding staff to assign a working DRG and to resolve discrepancies. Educates all internal customers on compliant documentation opportunities, coding and reimbursement issues. This standard includes formal presentations at physician meetings nursing and other staff meetings. Improves documented compliance of selected clinical quality indicators and problems present on admission. Other Job-Related Information: Working Conditions: Climbing - Rarely Hearing: Conversation - Consistently Hearing: Other Sounds - Consistently Kneeling - Occasionally Lifting 50 Lbs - Rarely Lifting <50 Lbs - Occasionally Pulling - Frequently Pushing - Consistently Reaching - Frequently Sitting - Rarely Standing - Consistently Stooping - Occasionally Talking - Consistently Use of Hands - Consistently Color Vision - Frequently Visual Acuity: Far - Consistently Visual Acuity: Near - Consistently Walking - Consistently TriHealth SERVE Standards and ALWAYS Behaviors At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following: Serve: ALWAYS… • Welcome everyone by making eye contact, greeting with a smile, and saying "hello" • Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist • Refrain from using cell phones for personal reasons in public spaces or patient care areas Excel: ALWAYS… • Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met • Offer patients and guests priority when waiting (lines, elevators) • Work on improving quality, safety, and service Respect: ALWAYS… • Respect cultural and spiritual differences and honor individual preferences. • Respect everyone’s opinion and contribution, regardless of title/role. • Speak positively about my team members and other departments in front of patients and guests. Value: ALWAYS… • Value the time of others by striving to be on time, prepared and actively participating. • Pick up trash, ensuring the physical environment is clean and safe. • Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste. Engage: ALWAYS… • Acknowledge wins and frequently thank team members and others for contributions. • Show courtesy and compassion with customers, team members and the community |
Job Summary
Full Time
Ambulatory Healthcare Services
$83k-103k (estimate)
05/24/2024
07/23/2024
trihealth.com
CINCINNATI, OH
7,500 - 15,000
1995
CHING HO
$500M - $1B
Ambulatory Healthcare Services
Related Companies
About TriHealth
TriHealth is physicians, hospitals, and communities working together to help you live better. The mission of TriHealth is to improve the health status of the people we serve. We pursue our mission by providing a full range of health related services including prevention, wellness and education. Care is provided with compassion consistent with the values of our organization. TriHealth is the healthcare system that formed as a partnership between Good Samaritan Hospital and Bethesda Hospital, Inc. TriHealth provides a wide range of clinical, educational, preventive and social programs. The syste ...
m also includes an ambulatory network, a research division, physician practices, corporate health, hospice care, a fitness and health pavilion, and other providers working together to improve the health status of the people it serves.
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