Niagara Health Corporation
Clinical Documentation Lead/Supervisor - St. Ann's
OH110_65002_000 Clinical Documentation
Expected Weekly Hours:
At Mount Carmel, we’re committed to making a meaningful difference in the lives of our patients and communities. Our colleagues – people like you – share our passion for always going above and beyond to provide the highest standards of care.
Job Description Details:
Our Clinical Documentation Professionals concurrently review medical records and assist physicians in removing the barriers between clinical and coding languages to allow more specific and complete documentation. The Lead/Supervisor for clinical documentation at each of our hospital sites leads a team of highly skilled clinical documentation specialists to ensure improvement in quality, completeness and accuracy of the medical recorddocumentation to support severity of illness, medical necessity and level of services rendered.
Manages a small, dedicated onsite team of CDI specialists to ensure quality of medical records throughout the hospital campus.
Responsible all things related to small team management, including but not limited to: scheduling, personnel development/training, etc.
Conducts concurrent reviews of selected patient records to address legibility, clarity, completeness, consistency, and precision of clinical documentation.
Demonstrates understanding of clinical documentation requirements to ensure that theseverity of illness, risk of mortality, and services provided are accurately reflected in therecord.
Serves as a resource on appropriate clinical documentation.
Communicates documentation discrepancies and coding definitions to the physicians both written and verbally as needed to clarify clinical documentation in accordance to query standards and/or policies.
Conduct 1:1 educational sessions with physicians and other healthcare team members related to specific documentation requirements.
Collaborates with the multi-disciplinary team, including physicians, patient care services, case management, coding specialists and other healthcare disciplines regarding clinical documentation issues.
Utilizes computer systems effectively and maintains record of reviews completed, queries completed and outcome of physician response.
Responsible for compliance with Organizational Integrity through raising questions and promptly reporting actual or potential wrongdoing.
Education: Associate/Diploma Degree in Nursing and five - ten years acute care medical orsurgical experience required. Bachelor of Science in Nursing preferred. A degree in HealthInformation Management with credentials of RHIA, RHIT, or CCS with extensive clinicalknowledge and a minimum of 5 years inpatient coding experience will be considered in lieuof an RN.
Licensure/Certification: Current license to practice as registered nurse in the State of Ohio.Registered Health Information Administrator (RHIA), Registered Health InformationTechnologist (RHIT), or Certified Coding Specialist (CCS) will be considered in lieu of a RN.
Experience: Minimum of 5 years acute care medical or surgical experience required;Utilization/Case Management, managed care, or Clinical Documentation and experience inICD-10 coding conventions and DRG methodology preferred.
Strong communication (verbal and written), interpersonal, organization and prioritization skills; Demonstrated ability to work effectively with physicians and handle multiple tasks and educational activities.
Ability to analyze, interpret and assimilate information from various sources.
Demonstrated knowledge in using clinical information systems and office automation.
Discovering opportunities, support and excellence – all while making a real difference in patients’ lives – begins at Mount Carmel. Find a new beginning and advance your career with us.
Mount Carmel and all its affiliates are proud to be equal opportunity employers. We do not discriminate on the basis of race, gender, religion, sexual orientation or physical ability.
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Our team of more than 10,000 employees, 1,600 physicians and 1,000 volunteers is committed to the quality care of our patients and their families. Together, we serve more than a million patients each year. And that number is certain to grow as we invest in our facilities and equipment over the next three years to transform our campuses in a way that will redefine healthcare in central Ohio. Mount Carmel is dedicated to more than just medical care. We’re dedicated to medical and nursing education and training as well, with six physician medical residency programs and Mount Carmel College of Nursing – one of the largest baccalaureate nursing degree programs in Ohio. In our effort to provide the highest-quality care, we’ve managed to provide award-winning care, too. Mount Carmel has received many local and national recognition for quality of care, associate and patient satisfaction, community involvement and philanthropy. Awards, facilities and services aside, we never forget that we’re a community-benefit ministry with a charitable mission. Each year Mount Carmel provides tens of millions of dollars in uncompensated benefits to the community. We’re also actively engaged in the community through business, civic and service organizations, and through our financial support of other not-for-profit organizations and social services agencies. Mount Carmel is a proud member of Trinity Health, one of the largest Catholic health care delivery systems in the nation.