Clinical Documentation Specialist- Health Information Management
Mercy Cedar Rapids
Cedar Rapids, IA
Permanent
Full-time
23 days ago
This position supports Mercy's philosophy of patient centered care by ensuring the patient's medical record is an accurate reflection of their medical condition and the services provided by Mercy Medical Center.Job DutiesReviews medical records to identify documentation opportunities.Communicates with physicians regarding documentation issues to ensure immediate resolution.Educates physicians and caregivers on the importance of complete and accurate clinical documentation as it is related to patient acuity, severity of illness, physician profiling and core measures.Assesses improvement in the quality of clinical documentation for area of responsibility.Adheres to all federal, state and Mercy Medical Center policies relating to medical records.Participates in meetings with physicians and other providers to discuss patient care documentation trends and improvement opportunities.Applies Medical Necessity criteria to determine payment eligibility.Gathers pertinent information regarding the claim/service that is being denied so that an appeal may be formulated and filed.Works closely with the out-patient areas of Mercy Medical Center and is a resource for them regarding their documentation needs in relation to the services they provide.Participates in providing education to physicians and other clinical staff.Participates in education and training of new CDS staff.Department Specific DutiesParticipates in concurrent quality reviews.Identifies and participates educational opportunities with providers and support staff.Utilizes CDI software effectively and efficiently to capture accurate and complete documentation.Assists with denials management related to medical necessity, quality and clinical validation denials.Collaborates with inpatient coding team for reconciliation of CDI coding DRG mismatch.Attends inpatient conference, rounding, shift change for collaboration with inpatient team.Knowledge, Skills and AbilitiesProficient in Microsoft Office products.Proficient in operation of computer, calculator, filing systems, copy/fax machines and telephone system.Excellent interpersonal skills.Excellent written and verbal communication skills.Excellent public relations and human relations - exemplifies The Mercy Touch.Excellent organizational and time management skills.Critical thinking, problem solving, and attention to detail skills.Exhibits good judgement.Handles confidential information with discretion and diplomacy.Commitment to life-long learning, e.g. willingness to learn/upgrade skills related to duties.Flexibility and dependability, works well with a wide variety of individuals and leadership styles.Ability to work with minimal to no supervision.Knowledge of Medicare Part AFamiliar with Medicare Part BKnowledge of regulatory environmentUnderstand and communicate differences between Medicare Part A and Part B Guidelines.Professional ExperienceRequired:Minimum two years acute care or equivalent clinical setting experiencePreferred:Knowledge of CPT and current ICD codes.Experience in critical careEducationRequired:Associate degree in NursingPreferred:Bachelor of Science in Nursing or other health related degreeLicensure, Certification, RegistrationRequired: Maintain current Registered Nurse licensure in the State of IowaRequired: Certification as Clinical Documentation Specialist within two years of hire or transferPhysical Demand RequirementsLight: Exert up to 20 lbs. of force occasionally and/or up to 10 lbs. of force frequently
