Nurse-Clinical Document Specialist - Remote

Employment Type

Full time

Shift

Day Shift

Description

POSITION PURPOSE

The Chart Documentation Specialist (CDS) works collaboratively with physicians, coders, nurses, and other patient care providers to improve the quality of chart documentation, and more accurately reflect the intensity of service and severity of illness. The CDS provides education and feedback to the medical staff one-on-one and in-group settings, regarding medical record documentation. The CDS reports activities quarterly and as needed to the Utilization Review & Chart Documentation Compliance Program Committee.

Scope Of Service/Customer

Customers include: physicians, nurse practitioners, staff nurses, Trinity Health staff, as well as the hospital’s Finance Department, and Executive Team.

Essential Functions

• Demonstrates general knowledge of computers. Demonstrates specific knowledge related to software programs such as Cerner/PowerChart, CDI software, and other appropriate software programs.
• Performs concurrent reviews of all components of the medical records to include assignment of DRG, identifying complications and co morbid conditions, and specific co-existing conditions.
• Interacts collaboratively with medical staff, nursing staff, coding staff, case managers and other patient care providers to improve the quality of chart documentation to accurately reflect the level of care and services provided.
• Demonstrates the ability to meets or exceeds Trinity Health’s CDI measures of performance.
• Accurately interprets clinical information in the medical record including but not limited to physician history and physicals, progress notes, consultations, diagnostic tests, medications, procedures, and nursing assessments.
• Performs initial case reviews and appropriate follow-up reviews.
• Complies with the Caring Model, Guiding Behaviors, Code of Ethics, and Professional Practice Standards.
• Attends and participates in periodic formal CDI education as required.
• Reports activities quarterly and as needed to the Utilization Review & Chart Documentation Compliance Program Committee.

2

• Attends and participates in monthly Trinity Health CDI meetings.
• Performs other duties consistent with the purpose of the job as directed.
• Attends and participates in monthly hospital CDI Task Force meetings.

Skills And Abilities Required

• Demonstrates the ability to work independently, and the ability to work collaboratively in a team environment.
• Exhibits knowledge, skills and abilities required to support compliance to age appropriate clinical documentation.
• Knows and adheres to all laws and regulations pertaining to patient health, safety and medical information. Demonstrates behaviors consistent with identified competencies and job requirements.
• Compiles information; keeps records, prepares or directs preparation of reports and correspondence.
• Communicates effectively with members of the health care team.
• Exhibits sound judgment, critical thinking, problem solving and decision making skills.

Working Conditions And Physical Demands

• Job requires exposure to marked changes in temperature and humidity and may be exposed to infectious disease, hazardous waste and chemicals.
• Job requires high level of mental concentration to attain established deadlines. Working environments includes frequent interruptions.
• During an 8-hour day, the associate must be able to stand/walk for 3 hours and sit 5 hours.
• Job requires the ability to frequently (21-50% of work time) lift and carry objects weighing approximately 11-24 pounds.
• Job requires occasional (6-10% of work time) squatting, crawling, crouching, kneeling, and balancing; frequent (21-50% of work time) bending, stooping, reaching above should level, pushing and pulling.
• Must have fine motor and manual dexterity skills to grip and manipulate items and perform repetitive action such as computer entry.
• Must be able to see at a near visual acuity level; able to speak and hear speech.

Minimum Education, Licensure, Certification, And Experience Required

• Previous Chart Documentation Specialist experience required.
• BSN or RN with Bachelors in health care-related field required.
• Three to five years’ clinical experience required.
• Current RN license to practice nursing in Iowa.

MERCY MODEL OF CARING (Addendum Attached)

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

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