Clinical Documentation Specialist

Employment Type

Full time

Shift

Day Shift

Description

JOB DESCRIPTION SUMMARY

We have an exciting job opportunity for experienced Clinical Documentation Specialist who are looking to join a resilient and exceptional team of nurses! Our team is dedicated to providing quality care and excellent outcomes.

[Insert Unit/Department description 2-3 sentences. Include unique scheduling or bonus information as needed]

Job Description

Manager, Clinical Documentation

Position Purpose: Must be able to set and organize own work priorities and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles. Must possess the ability to comply with Trinity Health policies and procedures. Must be able to spend majority of work time utilizing a computer, monitor and keyboard. Must be able to work with interruptions and perform detailed tasks. The position requires the ability to concentrate and read for long periods of time. Ability to work in an onsite and virtual environment.

What You Will Do

• Understanding of appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record.
• Assists in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes.
• Serves as a resource for appropriate clinical documentation.
• Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement.
• Identifies learning opportunities for healthcare providers. Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation.
• Formulates compliant clarifications/queries following Trinity Health’s documentation integrity procedures.
• Interacts with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification/query requests and educational opportunities. Accurately codes all relevant, appropriate and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR).
• Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care.
• Resolves all discrepancies in a courteous manner. Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgement and serves as a professional role model by demonstrating desirable practice behaviors.
• Proficient with leveraging the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness.
• Performs other duties as assigned by leadership. Maintains a 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, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior [Insert or remove additional qualification specific to unit/dept].
  
  

Minimum Qualifications: *GN’s or RN’s with < 1-year experience should apply to the Graduate Nurse Residency positions.

• Graduation from an accredited school of nursing and current licensure in the State of New York.
• Baccalaureate Degree in the Science of Nursing (BSN) degree from an accredited school of nursing preferred, according to NYS requirements.
• Specialty credentialing & educational degree according to clinical nursing practice specialty area preferred.
• Maintains all licensures and certifications according to NYS regulations and specialty area requirements.
• Participates in continuing education and updates and maintains knowledge and skills related to specific areas of expertise.
• [Insert or remove additional qualification specific to unit/dept].
  
  

Position Highlights And Benefits

• Our Trinity Health Culture: Our staff know, understand, incorporate & demonstrate our Trinity Health Mission, Values, Vision, through their actions, behaviors, practices & decisions. Our Unit practice counsels, and open-door guiding principle gives all our employees a voice.
• Professional Environment of Care: Practice in an environmentally safe, professional & healthy atmosphere. Only local hospital to receive a Leapfrog A for safety.
• Benefits: Comprehensive benefit packages available through Trinity Health, including medical, dental, vision, paid time off, 403B, and education assistance
• Professional Development: Strong education program, generous tuition allowance and clinical ladder incentives. We encourage job share opportunities to enhance satisfaction and growth. We encourage participation and support community programs and outreach.
• Work/Life: Scheduling options to balance work/life/school and recreational calendars.
  
  

Ministry/Facility Information.

Located in the heart of central New York, St. Joseph’s is one of America’s 50 Best Hospitals for Cardiac Surgery and one of America’s 100 Best for Spine Surgery and Coronary Intervention according to Healthgrades. It is ranked by Consumer Reports among the top 15 heart surgery centers in the country, a designated Stroke Center, a U.S. News “Best Regional Hospital” and “Best Maternity Hospital”. With a comprehensive range of primary-care practices, mental health services, women's and infants' care, and oncology services, St. Joesph’s Health network offers a wide range of innovative, community-based health and wellness programs. Our high-quality specialty and mental health services aim to coordinate the continuum of care, as a compassionate healing presence to improve all aspects of health. Joining our team means becoming part of a nationally recognized, elite group of healthcare professionals who are passionate about patient care and supporting one another.

The above statements are intended to describe the general nature & level of work being performed by persons assigned to this classification. They are not to be construed as an exhaustive list of duties so assigned.

Pay Range: $36.65- $56.95

Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.

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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.