Remote Registered Nurse Job( Clinical Documentation Specialist )

Hiring Organization: Trinity Health

Post Name: Clinical Documentation Specialist

Qualification: Graduate

Industry: Private

Employment Type: Full Time

Work Hours: 8 Hours

Salary: $20 – $30/Hour

Location: Michigan, USA

Full Job Description

Leverage advanced clinical and coding expertise to guide clinical documentation integrity efforts through the roles of reviewers, trainers, and consultants. Facilitate the overall quality, completeness, accuracy and integrity of medical records through a thorough review of records.

Through extensive interactions with physicians and other members of the healthcare team, achieve appropriate clinical documentation to support the establishment of codes, medical needs, disease severity, risk of death, and level of care provided to all patients. Participate in the development and delivery of training for healthcare providers and team members.

Remote Registered Nurse Job( Clinical Documentation Specialist )

BASIC FUNCTION

• Know, understand, integrate and demonstrate Trinity Health's mission, vision and values ​​in behaviour, practices, standards, policies, procedures and decisions.
• Demonstrate an understanding of appropriate clinical documentation to ensure disease severity, risk of death and level of services provided are accurately reflected in medical records. Support the overall quality, timeliness, and completeness of health records to ensure adequate data, provider communication, and quality outcomes. Serves as a resource for appropriate clinical documentation.
• Communicating and educating physicians and all other members of the healthcare team about clinical documentation and monitoring provider engagement. Identify training opportunities for healthcare providers.
• Perform concurrent reviews of selected patient records to enhance the readability, clarity, completeness, consistency, and accuracy of clinical documentation.
• Formulate appropriate clarifications/requests per Trinity Health documentation integrity procedure.
• Interact with doctors, nurses, and support staff regarding appropriate documentation requirements, requests for clarification/questions, and educational opportunities.
• Coding all relevant, appropriate and compatible working diagnosis codes and establishing a working primary diagnosis and a working DRG (MS or APR).
• Work with coding staff to ensure documentation of discharge and comorbid diagnoses fully reflects the patient's clinical status and treatment. Resolve disagreements in a polite manner.
• Demonstrate expertise in problem-solving skills based on theoretical knowledge, clinical experience and sound judgment, and serve as a professional role model by demonstrating the desired behavior in practice.
• Uses 3M/360 functions to enter data regarding CDI efficacy and effectiveness.
• Perform other tasks assigned to him by senior management.
• Maintain knowledge of applicable federal, state and local laws and regulations, accreditation bodies, Trinity Health's organizational integrity program, standards of conduct, codes of conduct, and other policies and procedures to ensure compliance in a fair, ethical, and reflective manner professional .

MINIMUM QUALIFICATIONS

• Must have an Associate/Diploma degree in Nursing or Health Information Technology (HIT) or equivalent education and experience.
• Must have one of the following:
• Current license to practice as a nurse,
• Registered Health Information Administrator (RHIA),
• Registered Health Information Technician (RHIT),
• Certified Programming Specialist (CCS),
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP).
• Two (2) years critical care, inpatient medical or surgical nursing experience, preferably as an RN, related field, or inpatient coder.
• Excellent communication (oral and written), interpersonal skills, collaboration and relationship building skills. Strong critical thinking skills and ability to integrate knowledge. Priority and organizational skills required. Effective presentation/facilitation skills to achieve educational goals for all members of the healthcare team.
• Demonstrate ability to use standard desktop and Windows-based computer systems, including a basic understanding of e-mail, the Internet, and computer navigation. Ability to use other software as needed to perform core functions while working. Experience with databases, spreadsheet software and presentation software is desirable.
• Data entry and typing skills at least 30 wpm.
• You should be comfortable working independently and in a collaborative environment.
• Must have a personal presence characterized by a sense of honesty, integrity and caring, with the ability to inspire and motivate others to advance Trinity Health's philosophy, mission, vision, goals and values.

Remote Registered Nurse Job( Clinical Documentation Specialist )