Clinical Documents Specialist

Novant Health; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

Novant Health offers an exciting opportunity for an Acute Care, Clinical Documentation Specialist. This role plays a critical part in ensuring high-quality clinical documentation reflecting patient care. Join a diverse team committed to delivering remarkable healthcare outcomes for our community. Ideal candidates will have extensive nursing experience, possess strong communication skills, and be prepared to adapt quickly to new healthcare technologies.

Qualifications

• Five years of nursing experience required.
• Current RN licensure in appropriate state required.
• Certified Clinical Documentation Specialist (CCDS) preferred.

Responsibilities

• Facilitating improvement in clinical documentation quality.
• Educating providers to ensure accurate documentation.
• Reviewing inpatient medical records for documentation improvement.

Skills

Communication

Teamwork

Change Readiness

Education

High School Diploma or GED

BSN, BS/BA in a related healthcare field

MSN, MA, M.Ed or other graduate degree in a related healthcare field

Tools

Electronic Medical Record Systems

Microsoft Office

Job description

Job Summary

The Acute Care, Clinical Documentation Specialist is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. The Acute Care, Clinical Documentation Specialist, (CDS) reviews acute care, inpatient, medical records to identify and resolve documentation improvement opportunities, in accordance with Clinical Documentation Excellence (CDE) program guidelines. This position will be responsible for assisting and educating treating providers to ensure that documentation in the inpatient medical record accurately reflects the patient's severity of illness and risk of mortality, to ensure reliable clinical outcomes reporting. The CDI Specialist assesses clinical documentation through extensive review of the medical record, completes needed diagnosis specificity or diagnosis clinical validation through compliant query practice, and interaction with physicians, APPs, and Health Information Management (HIM) coding team members to ensure that the clinical information utilized in profiling and reporting outcomes is complete and accurate.

At Novant Health, one of our core values is diversity and inclusion. By engaging the strengths and talents of each team member, we ensure a strong organization capable of providing remarkable healthcare to our patients, families and communities. Therefore, we invite applicants from all group dynamics to apply to our exciting career opportunities.

#nursingatnovanthealth

Responsibilities

It is the responsibility of every Novant Health team member to deliver the most remarkable patient experience in every dimension, every time.

• Our team members are part of an environment that fosters team work, team member engagement and community involvement.
• The successful team member has a commitment to leveraging diversity and inclusion in support of quality care.
• All Novant Health team members are responsible for fostering a safe patient environment driven by the principles of "First Do No Harm".

Qualifications

• Education: High School Diploma or GED, required. BSN, BS/BA in a related healthcare field, preferred. MSN, MA, M.Ed or other graduate degree in a related healthcare field preferred.
• Experience:
  • Five years of nursing experience, required.
  • Two years Clinical Documentation Improvement, HIM or other related field, preferred.
  • One year Critical Care Inpatient Nursing Experience, preferred.
  • Two yeas Acute Care, inpatient nursing experience, preferred.
• Licensure/Certification:
  • Current RN licensure in appropriate state, required.
  • Certified Clinical Documentation Specialist (CCDS), preferred.
  • CCS (Certified Coding Specialist), CCA (Certified Coding Associate) or other in-patient coding certification, preferred.
  • Certified Documentation Improvement Practitioner (CDIP), preferred.
• Additional Skills (required):
  • • Ability to successfully complete generic and department-specific skills validation and competency testing
    • Working knowledge of Microsoft Office products
    • Proficiency in the electronic medical record and ability to adapt and adjust quickly to technology enhancements, upgrades and new modalities/software products
    • Change readiness and ability to adapt and adjust quickly to process change
    • Incorporates process improvement and continuous learning to stay abreast of industry updates/guideline changes:
    • Maintains individual continuing education requirements for AHA Coding Clinic for ICD-10 CM and ICD-10 PCS (Procedure coding system) updates which take place quarterly (quarterly publication of the Central Office on ICD-10-CM/PCS)
    • Maintains individual continuing education requirements for the ICD-10-CM Official Guidelines for Coding, updates which take place yearly. (These guidelines are approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS.)
    • Maintains individual continuing education requirements for the ICD-10-PCS Official Guidelines for Coding and Reporting which also take place yearly. (These guidelines are approved by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS) which provide the following guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)
• Additional Skills (preferred): Training and development background with previous experience with educational platform development and or presentation experience is preferred.

Job Opening ID

93129

• Education: High School Diploma or GED, required. BSN, BS/BA in a related healthcare field, preferred. MSN, MA, M.Ed or other graduate degree in a related healthcare field preferred.
• Experience:
  • Five years of nursing experience, required.
  • Two years Clinical Documentation Improvement, HIM or other related field, preferred.
  • One year Critical Care Inpatient Nursing Experience, preferred.
  • Two yeas Acute Care, inpatient nursing experience, preferred.
• Licensure/Certification:
  • Current RN licensure in appropriate state, required.
  • Certified Clinical Documentation Specialist (CCDS), preferred.
  • CCS (Certified Coding Specialist), CCA (Certified Coding Associate) or other in-patient coding certification, preferred.
  • Certified Documentation Improvement Practitioner (CDIP), preferred.
• Additional Skills (required):
  • • Ability to successfully complete generic and department-specific skills validation and competency testing
    • Working knowledge of Microsoft Office products
    • Proficiency in the electronic medical record and ability to adapt and adjust quickly to technology enhancements, upgrades and new modalities/software products
    • Change readiness and ability to adapt and adjust quickly to process change
    • Incorporates process improvement and continuous learning to stay abreast of industry updates/guideline changes:
    • Maintains individual continuing education requirements for AHA Coding Clinic for ICD-10 CM and ICD-10 PCS (Procedure coding system) updates which take place quarterly (quarterly publication of the Central Office on ICD-10-CM/PCS)
    • Maintains individual continuing education requirements for the ICD-10-CM Official Guidelines for Coding, updates which take place yearly. (These guidelines are approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health Information Management Association (AHIMA), CMS, and NCHS.)
    • Maintains individual continuing education requirements for the ICD-10-PCS Official Guidelines for Coding and Reporting which also take place yearly. (These guidelines are approved by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS) which provide the following guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)
• Additional Skills (preferred): Training and development background with previous experience with educational platform development and or presentation experience is preferred.

It is the responsibility of every Novant Health team member to deliver the most remarkable patient experience in every dimension, every time.

• Our team members are part of an environment that fosters team work, team member engagement and community involvement.
• The successful team member has a commitment to leveraging diversity and inclusion in support of quality care.
• All Novant Health team members are responsible for fostering a safe patient environment driven by the principles of "First Do No Harm".