THIS IS A COLLECTIVE BARGAINING UNIT POSITION
Job Description
Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains and promotes appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers and Health Information Management coding staff to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of patient care team on documentation guidelines, on an on-going basis.
Essential Functions:
Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record
Performs admission reviews for specific patient populations using clinical documentation guidelines
Assists in medical screening process by documenting appropriateness of patient admission, working DRG & LOS info on worksheet and computer system as appropriate
Extensively reviews all physician and clinical documentation, lab results, diagnostic information, and treatment plans and captures appropriate information on CDMP® worksheet
Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, acuity and resource consumption
Verbally communicates with appropriate physician(s) to ensure documentation opportunities are clarified
Communicates with ancillary personnel (e.g., PT, ET) to clarify potential documentation opportunities
Updates DRG worksheet to reflect any changes in patient status, procedures/treatments, and confers with physician to finalize diagnoses.
Reviews medical record every 24-48 hours as appropriate
Updates Clinical Documentation Management Program worksheet to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate
Updates Clinical Documentation Management Program worksheet to reflect any changes in DRG assignment
Communicates with physician to ensure that request for documentation has been noted
Confers with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures
Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in patient’s chart
As appropriate, documents, analyzes data and reports instances of inappropriate patient care, discharge delays, etc. to Manager of Health Records Services
Collaborates with coding staff as needed to determine appropriate DRG and required documentation
Stays current with and conducts on-going clinical documentation management program education for new staff, including new clinical documentation specialists, physicians and nursing and allied health professionals. Tracks and trends program compliance
Participates in concurrent performance improvement activities and on-going MR review activities
Maintains positive and open communications with physicians, interdisciplinary care team members, coding staff, Regional Manager of Coding, Quality and Compliance
Qualifications:
Registered Nurse (RN) with 5+ years of experience in Med/Surg, Critical Care, ICU, or ED experience required
Active RN license in Ohio or Kentucky required
Certified Clinical Documentation Specialist (CCDS) preferred
70% or greater on JA Thomas's Clinical Competency Assessment required
Excellent interpersonal skills including verbal and written communication skills required as well as the ability to demonstrate excellent physician relations
As a Bon Secours Mercy Health associate, you're part of a Mission that matters. We support your well-being—personally and professionally. Our benefits are built to grow with you and meet your unique needs, every step of the way.
What we offer
Competitive pay, incentives, referral bonuses and 403(b) with employer contributions (when eligible)
Medical, dental, vision, prescription coverage, HSA/FSA options, life insurance, mental health resources and discounts
Paid time off, parental and FMLA leave, short- and long-term disability, backup care for children and elders
Tuition assistance, professional development and continuing education support
Benefits may vary based on the market and employment status.
All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Bon secours Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email
[email protected]
. If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at
[email protected]
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Questions:
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Are you a *current* employee of Bon Secours Mercy Health, Roper St. Francis Healthcare or a Bon Secours Mercy Health facility? Current Agency Employees that are working on site at Bon Secours Mercy Health or Roper St. Francis Healthcare are not considered current employees and should answer no to this question.
- Yes. Current employees must log into Workday and submit a transfer application via Browse Jobs.
- No
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Are you a current employee of any Bon Secours Mercy Health partner affiliates (Ensemble)?
- Yes
- No
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Are you legally authorized to work in the United States?
- Yes
- No
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Will you now or in the future require the organization to commence (“sponsor”) an immigration case in order to employ you (for example, H-1B or other employment-based immigration case)?
- Yes
- No
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Are you able to perform the essential, job-related functions of the position for which you are applying with or without reasonable accommodation?
- Yes
- No
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Do you currently hold a relevant valid professional license, certification, or registration, or (if required for the position to which you are applying) do you expect to meet this qualification prior to starting in this position? If the position to which you are applying does not require a professional license, certification, or registration, please select No.
- Yes
- No
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Have you been excluded, or are you currently under investigation for healthcare fraud, abuse, or misconduct; or restricted from participating in any Federal or State healthcare program, including Medicare and/or Medicaid?
- Yes
- No