Associate Clinical Documentation Improvement Specialist - Part Time

Mercy Hospital St. Louis Critical Care Medicine Fellowship; Joplin (MO); On-site; USD 65,000 - 95,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision coverage

Paid time off

Tuition support

Matched retirement plan

Job summary

Mercy is seeking a Clinical Documentation Specialist to perform concurrent and retrospective reviews of inpatient medical records, ensuring accurate, complete documentation of patient encounters. You will work with inpatient teams to reflect true clinical scenarios, severity, and intensity of services.

Minimum qualifications include RN/BSN and coding/HIM credentials or equivalent experience. Strong critical thinking, communication skills, and proficiency with Excel and Word are required to

Qualifications

• RN, BSN, RHIA, RHIT, CCS, CPC, CIC, CCDS, or CDIP required.
• 1 year of acute care inpatient nursing, coding, or HIM experience.
• Strong critical thinking and communication skills.
• Ability to plan and organize workflow to meet deadlines.
• Proficient computer skills including typing and data entry.
• Experience with DRG concepts knowledge is a plus.

Responsibilities

• Perform concurrent and retrospective reviews of inpatient medical records to ensure accurate, complete documentation.
• Collaborate with inpatient care providers to reflect true clinical scenarios, SOI, ROM, and service intensity.
• Maintain confidentiality and adhere to Mercy Service Standards.
• Interpret clinical data and communicate findings effectively to care teams.

Skills

Critical thinking

Communication skills

Planning & organization

Computer skills

Data entry

Record review

Clinical knowledge

Team collaboration

Flexibility

Confidentiality

Education

RN, BSN, RHIA, RHIT, CCS, CPC, CIC, CCDS, or CDIP

Tools

Excel

Word

Job description

Job Description

Find your calling at Mercy!

Job Profile Summary

The Clinical Documentation Specialist provides clinically based, concurrent and retrospective reviews of inpatient medical records. Will work to identify opportunities and ensure accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes. This position collaborates with inpatient care providers to ensure accurate, complete, compliant, concise, and consistent documentation that reflects the true clinical scenario of the patient’s encounter. This additionally serves to reflect the true Severity of Illness (SOI), Risk of Mortality (ROM), and intensity of services rendered to provide quality care and treatment to the patient.

Performs duties and responsibilities in a manner consistent with our mission, values, and Mercy Service Standards.

Position Details:

Minimum Required Qualifications

Education:

RN, BSN, RHIA, RHIT, CCS, CPC, CIC, CCDS, or CDIP

Experience:

1-year related experience in acute care inpatient nursing or inpatient coding or HIM

Other Skills And Knowledge:

• Excellent critical thinking skills with the ability to quickly make decisive decisions from limited written and/or verbal information, excellent reading comprehension
• Excellent communication skills (written and verbally) and comfortable speaking in groups.
• Ability to plan and organize workflow in order to meet deadlines
• Must have strong computer skills including typing ability.
• Experience with computer programs (EXCEL, Word)
• Data entry
• Record review with ability to interpret clinical data
• Strong clinical knowledge
• Ability to establish cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines and interact with all levels of employees
• Ability to work flexible work schedules to accommodate provider rounding schedules and required medical staff presentations
• Employee should possess: the ability to work with minimum supervision; organizational and administrative skills; function in a stressful environment; encourage and assist with team building; and the ability to maintain the confidentiality of sensitive information, both patient and employee
• Detail oriented
• Ability to work independently

Preferred Qualifications

RN, CCS, CPC, RHIA, RHIT, or a combination thereof

Experience:

3 years nursing, inpatient coding, or other HIM role in acute hospital setting

Knowledge of diagnosis-related groups (DRG), prospective payment systems, and hospital quality performance initiative.

Utilization review/case management experience

Certification/Registration: CCDS (Certified Clinical Documentation Specialist) from ACDIS or CDIP (Certified Documentation Improvement Practitioner) from AHIMA preferred

Why Mercy?

From day one, Mercy offers outstanding benefits - including medical, dental, and vision coverage, paid time off, tuition support, and matched retirement plans for team members working 32+ hours per pay period.

Join a caring, collaborative team where your voice matters. At Mercy, you'll help shape the future of healthcare through innovation, technology, and compassion. As we grow, you'll grow with us.