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CDI RN – Clinical Documentation Specialist Registered Nurse

Trinity Health
Sioux City, United Statesfull_timeVerifiedPosted 20 Jun 2025

About the role

Employment Type:

Full time

Shift:

Day Shift

Description:

At MercyOne, health care is more than just a doctor’s visit or a place to go when you’re in need of medical attention. Our Mission is based on improving the health of our communities – that means not only when you are sick but keeping you well.

MercyOne Siouxland Medical Center has earned more national recognition for quality patient outcomes than any other hospital in the region. The medical center has earned multiple honors for its leadership and excellence in several clinical areas including cardiac care, orthopedic services, vascular surgery, stroke care and cancer care.

Want to learn more about MercyOne Sioux City? Click here:

Find a Location Sioux City, Iowa (IA), MercyOne Siouxland 

 

Join the MercyOne Family! We are looking to hire a Registered Nurse (RN). 

 

As an RN at MercyOne, you will recognize and understand the legal boundaries for practicing nursing within the scope of nursing practice. Per the Iowa Board of Nursing, the scope of practice of the registered nurse is determined by the nurse’s education, experience, and competency and the rules governing nursing. Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence.   

 

Schedule: 

Full time, 40 hours per week, no weekends or holidays 

 

General Requirements: 

  • 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, quality indicators and level of services provided are accurately reflected in the health recordAssists in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomesServes 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 engagementIdentifies 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.

  • 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 careResolves 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.

  • Leverages the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness.

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Company

Trinity Health

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