Employment Type:

Full time

Shift:

Day Shift

Description:

RN Clinical Documentation Specialist

Full-time day shift

St. Peter's Hospital in Albany, NY

Position Highlights:

• Recognized leader: Magnet Hospital in the Capital Region

• Quality of Life: Where career opportunities and quality of life converge

• Advancement: Strong orientation program, generous tuition allowance and career development

What you will do:

The 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.

PRIMARY JOB RESPONSIBILITIES AND DUTIES:

Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, standards, policies, procedures and decisions. Demonstrates 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.

MINIMIUM QUALIFICATIONS, REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR and Advanced degree in nursing or medical field such as NP/APN or PA. 

Must possess one of the below:

Current Registered Nurse License,

Registered Health Information Administrator (RHIA),

Registered Health Information Technician (RHIT),

Certified Coding Specialist (CCS) required,

licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school. 

Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred. Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred.  Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills.  Strong critical thinking skills and ability to integrate knowledge.  Prioritization and