Clinical Documentation Specialist-Remote

Employment Type

Full time

Shift

Day Shift

Description

Why Mount Carmel?

With five hospitals, over 60 free-standing outpatient clinics, a college of nursing, a Medicare Advantage plan, and extensive outreach and community wellness programs, Mount Carmel Health System serves more than a million patients in central Ohio each year, and we've been a pillar of this community for more than 130 years. As a proud member of Trinity Health, one of the nation's largest Catholic healthcare delivery systems, our network of caring spans 22 states, 94 hospitals, and 133,000 colleagues nationwide.

We know that exceptional patient care starts with taking care of our colleagues, so we invest in great people and all that we ask in return is that you come to work ready to make a difference and do the right thing.

What We Offer

• Competitive compensation and benefits packages including medical, dental, and vision coverage
• Retirement savings account with employer match starting on day one
• Generous paid time off programs
• Employee recognition incentive program
• Tuition/professional development reimbursement
• Relocation assistance (geographic restrictions apply)
• Discounted tuition and enrollment opportunities at the Mount Carmel College of Nursing
  
  

Why Columbus?

The nation's 14th largest city, Columbus, Ohio is one of the fastest growing major metropolitan areas in the Midwest – ranked #1 for population growth, #1 for job growth, #1 for wage growth, and #1 real estate market. And with a vibrant blend of professional sports, world-class attractions, creative cuisines, and a flourishing music and arts scene, you'll never be found wanting for entertainment and experiences to call your own in Columbus. Learn more at www.experiencecolumbus.com!

Essential Responsibilities

• 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.
  
  

Other Job Responsibilities

• 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.
  
  

Job Qualifications (Knowledge, Skills, And Abilities)

• 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, managed care, or Clinical Documentation and experience in
• ICD-10 coding conventions and DRG methodology preferred.
• Effective Communication Skills
• Strong communication (verbal and written), interpersonal, organization and prioritization skills. Demonstrated ability to work effectively with physicians and handle multiple tasks and educational activities.
• Ability to work independently and be self-directed.
• Ability to analyze, interpret and assimilate information from various sources.
• Demonstrated knowledge in using clinical information systems and office automation.
• Possesses effective interpersonal skills, can work across departmental boundaries, facilitates problem resolution, and maintain a professional demeanor in difficult situations.
• Possesses enthusiasm and motivation to stimulate diverse individuals and groups.
  
  

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.

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