Position Summary:
Utilizes advanced coding and/or clinical expertise to direct efforts toward the improvement of clinical documentation through the roles of educator and consultant. Facilitates improvement in the overall quality, completeness, and accuracy 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 the medical necessity and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.
What you will do:
Demonstrates understanding of and facilitates 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 quality 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 participation. 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.Collaborates with coding staff to assure 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.Provide guidance, assistance and problem resolution as needed to staff.What you will need:
Must possess a comprehensive knowledge of acute care nursing experience, as normally obtained through a Bachelor of Science, Nursing (BSN) and five (5) years on a medical or surgical unit, or Bachelor of Science in Health Information Management (HIM) and five (5) years HIM/inpatient coding experience, or an Associate/Diploma Degree in Nursing and ten (10) years on a medical or surgical unit, or an Associate Degree in Health Information Technology or in a related healthcare field. Ten (10) years' experience in acute inpatient coding preferredCurrent Registered Nurse License in the State of practice, Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Coding Specialist (CCS). Certified Clinical Documentation Specialist (CCDS) preferredExperience in Critical Care, Utilization Management/Case Management, Clinical Documentation, ICD9 Coding Guidelines and DRG assignment or patient outcomes/quality management, preferred. Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team.Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.