Clinical Documentation Specialist

Mercy Medical Center

This position supports Mercy's philosophy of patient centered care by ensuring the patient's medical record is an accurate reflection of their medical condition and the services provided by Mercy Medical Center.
  • Job Duties/Essential Functions
    • Job Duties
      • Reviews medical records to identify documentation opportunities.
      • Communicates with physicians regarding documentation issues to ensure immediate resolution.
      • Educates physicians and caregivers on the importance of complete and accurate clinical documentation as it is related to patient acuity, severity of illness, physician profiling and core measures.
      • Assesses improvement in the quality of clinical documentation for area of responsibility.
      • Adheres to all federal, state and Mercy Medical Center policies relating to medical records.
      • Participates in meetings with physicians and other providers to discuss patient care documentation trends and improvement opportunities.
      • Applies Medical Necessity criteria to determine payment eligibility.
      • Gathers pertinent information regarding the claim/service that is being denied so that an appeal may be formulated and filed.
      • Works closely with the out-patient areas of Mercy Medical Center and is a resource for them regarding their documentation needs in relation to the services they provide.
      • Participates in providing education to physicians and other clinical staff.
      • Participates in education and training of new CDS staff.

    • Department Specific Duties
      • Assists with Quality Review for staff.
      • Identifies educational opportunities with other caregivers and support personnel.
  • Knowledge, Skills and Abilities
    • Proficient in Microsoft Office products.
    • Proficient in operation of computer, calculator, filing systems, copy/fax machines and telephone system.
    • Excellent interpersonal skills.
    • Excellent written and verbal communication skills.
    • Excellent public relations and human relations - exemplifies The Mercy Touch.
    • Excellent organizational and time management skills.
    • Critical thinking, problem solving, and attention to detail skills.
    • Exhibits good judgement.
    • Handles confidential information with discretion and diplomacy.
    • Commitment to life-long learning, e.g. willingness to learn/upgrade skills related to duties.
    • Flexibility and dependability, works well with a wide variety of individuals and leadership styles.
    • Ability to work with minimal to no supervision.
    • Knowledge of Medicare Part A
    • Familiar with Medicare Part B
    • Knowledge of regulatory environment
    • Understand and communicate differences between Medicare Part A and Part B Guidelines.
  • Professional Experience
    • Required:
      • Minimum two years acute care or equivalent clinical setting experience
    • Preferred:
      • Knowledge of CPT and current ICD codes.
      • Experience in critical care
  • Education
    • Required:
      • Associate degree in Nursing
    • Preferred:
      • Bachelor of Science in Nursing or other health related degree
  • Licensure, Certification, Registration
    • Required:  Maintain current Registered Nurse licensure in the State of Iowa
    • Preferred:  Certification as a Clinical Documentation Specialist

Location: Mercy Medical Center - Cedar Rapids · Health Information Management
Schedule: Full Time, Day, 7a to 3:30 p M-F

Job ID: 81621

Posted 23 days ago

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