Registered Nurse (RN) Clinical Documentation Specialist - SS Revenue Cycle - Work at Home - Ohio Toledo Market

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 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 – 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]