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Hours Full-time, Part-time
Location Columbus, OH
Columbus, Ohio

About this job

* 3 - 5 years of experience required

* We are seeking a Clinical Documentation Specialists to join our team of dedicated professionals as we continue our mission of improving the health of the communities we serve.

Job Summary

In accordance with the Mission and Guiding Behaviors; the Clinical Documentation Specialists will concurrently review medical records and assist physicians in removing the barriers between clinical and coding languages to allow more specific and complete documentation. Through interaction with the physicians and other members of the healthcare team, facilitates improvement in quality, completeness and accuracy of the medical record documentation to support severity of illness, medical necessity and level of services rendered.

Essential Responsibilities

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) required.

Experience: Minimum of 5 years acute care medical or surgical experience required;

Utilization/Case Management, managed care, or Clinical Documentation and experience in

ICD-9 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.

About Mount Carmel

Serving more than a million patients each year, Mount Carmel is the preferred healthcare provider in central Ohio. Our more than 8,500 employees and 1,500 physicians utilize state-of-the-art facilities, advanced technologies and the latest procedures to accomplish our mission of healing patients' minds, bodies and spirits, and improving the health of the communities we serve.