Clinical Documentation Specialist Remote

MercyOne Medical Group; Davenport (IA); Remote; USD 70,000 - 100,000; Full time

Job summary

MercyOne Medical Group is seeking a Clinical Documentation Specialist to ensure the integrity and accuracy of medical record documentation. The role focuses on reviewing, educating, and consulting with clinicians to reflect severity of illness and services provided.

Qualified candidates will have an HIT degree or advanced nursing/PA degree, with relevant inpatient experience and certifications. Strong communication and organizational skills are required for collaboration with the care team.

Qualifications

• Must have an Associate/Diploma in HIT or an advanced nursing degree; if no degree, 3 years inpatient code/clinical documentation experience.
• Preferred certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP.
• Experience in critical care, medical or surgical inpatient care nursing as RN/PA/NP/APN or inpatient coder preferred.
• Excellent communication, interpersonal, collaboration and relationship-building skills; strong critical thinking and organization.
• Data entry and typing skills at minimum 30 wpm.

Responsibilities

• Knows, understands, incorporates and demonstrates the Trinity Mission, Vision and Values in behaviors and decisions.
• Demonstrates understanding of appropriate clinical documentation to reflect severity of illness, mortality risk, quality indicators and level of services.
• Communicates with physicians and healthcare team in clinical documentation and monitors provider engagement.
• Conducts concurrent reviews of selected patient records to address legibility, clarity, completeness, and precision of documentation.
• Formulates clarifications/queries following Trinity Health's documentation integrity procedures.

Skills

Communication

Interpersonal

Collaboration

Critical thinking

Data entry

Typing 30 wpm

Organization

Education

Associate/Diploma in HIT

Advanced nursing degree (NP/APN) or PA

RN/RHIA/RHIT/CCS/CDDS/CDIP

Tools

Windows OS

Job description

Employment Type:Full timeShift:Day ShiftDescription:MercyOne Genesis Full-Time Remote Position (80 Hours Biweekly)

AA degree in Nursing or HIT. In absence of degree, 3 years' experience as an inpatient code or clinical documentation specialist.

Position Purpose:

Utilizes clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness and accuracy of medical record documentation through extensive record review.

Essential Functions:

• Knows, understands, incorporates and demonstrates the Trinity Mission, Vision and Values in behaviors, practices, standards policies procedures and decisions.
• Demonstrates understanding of appropriate clinical documentation to ensure the severity of illness, risk of mortality, quality indicators and level of services provided are accurately reflected in the health record.
• Communicates with and educates physicians and all other member of the healthcare team in clinical documentation and monitors provider engagement.
• Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation.
• Formulates compliant clarifications/queries following Trinity Health's documentation integrity procedures.

Minimum Qualifications:

• Must possess an Associate/Diploma Degree in Health Information Technology (HIT) or Advanced degree in nursing (NP, APN) or Physician Assistant. In absence of college degree, must have three (3) years' experience as an inpatient code or documentation specialist.
• Preferred Certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP
• Experienced in critical care, medical or surgical inpatient care nursing as an RN, PA, NP, APN or inpatient coder preferred
• Excellent communication, interpersonal, collaboration and relationship building skills. Strong critical thinking skills, and ability integrate knowledge. Prioritization and organizations skills required.
• Demonstrated ability to use standardized desktop and Windows based computer system. Data entry and typing skills at minimum 30 wph.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are 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, veteran status, or any other status protected by federal, state, or local law.