Associate Clinical Documentation Improvement Specialist - Part Time

Mercy; Joplin (MO); On-site; USD 65,000 - 85,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Tuition support

Matched retirement plans

Job summary

Mercy is seeking a Clinical Documentation Specialist to conduct concurrent and retrospective reviews of inpatient medical records. You will identify opportunities to improve clinical documentation accuracy and reflect the true scenario of patient encounters.

Join Mercy to ensure documentation supports SOI and ROM, while collaborating with care teams to maintain high quality care and compliance standards.

Qualifications

• RN/BSN or RHIA/RHIT/CCS/CPC/CIC/CDDS/CDIP credentials required.
• 1 year of acute care inpatient nursing, coding or HIM experience.
• Strong analytical and communication skills; ability to work with diverse teams.

Responsibilities

• Perform concurrent and retrospective reviews of inpatient medical records.
• Identify opportunities to improve accuracy and completeness of clinical documentation.
• Collaborate with inpatient care providers to reflect true SOI, ROM and intensity of services.

Skills

Critical thinking

Communication skills

Workflow planning

Data entry

Excel

Word

Team collaboration

Confidentiality

Independence

Education

RN

BSN

RHIA

RHIT

CCS

CPC

CIC

CDDS

CDIP

Tools

EXCEL

Word

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

Education

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

Other Skills And Knowledge

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.