The Clinical Documentation Specialist ensures clinical documentation is accurate, compliant and specific to reflect the severity of illness and risk of mortality of the patient. Facilitates concurrent documentation of the medical record to realize accurate and complete representation of the Severity of Illness and Risk of Mortality of the patient, resulting in the appropriate ICD-10 code\/DRG assignment. Works collaboratively with medical, nursing, ancillary, and coding staff to improve the quality of chart documentation. Responsible for identifying complications and co-morbid conditions, specifying co-existing conditions and causal agents, and following-up with physicians responsible for care of the patient for appropriate documentation. Identifies the need to clarify documentation in the medical record and communicates with physicians face-to-face or using the appropriate \u201cquery\u201d tools. Stays abreast of coding guidelines, reimbursement methodologies, regulatory compliance and quality based programs. Maintains thorough and current knowledge of clinical care and treatment options to critically assess appropriateness of documentation. Thorough clinical knowledge of disease processes, pathophysiology and pharmacology is required. Serves as a resource and educates physicians on linking coding guidelines and medical terminology to capture accurate final code assignment. Promotes mission, vision, and values of SCL Health, and abides by service behavior standards. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.\u00a0 Understands and is able to articulate concepts to physicians and other health care professionals in an effort to educate on clinical documentation requirements. Required: Bachelor\u2019s level degree in Nursing required. Active RN license in good standing required. Three (3) years of nursing experience in an acute care setting within the last 10 years or 1 or more year experience as a Clinical Documentation Specialist in an acute care setting within the past 2 years required. Preferred: CDIP or CCDS certification preferred. CDI experience preferred. 3MCDIS and Epic preferred or ability to learn.
Website : http://www.stvincent.org
We are all defined, in part, by what we do. For St.Vincent, that means the accumulated experience of more than 130 years of dedicated service to the improved health of our Indiana community. As member of Ascension Health, the largest Catholic health care system in the country, our mission is to care for the bodies, minds, and spirits of those in need, regardless of personal means or religious affiliation. At St.Vincent, we’re dedicated to providing spiritually-centered, holistic care, that sustains and furthers both individual and community health. With 22 health ministries serving 57 counties in central and southern Indiana, our facilities include: A major, 4 building medical complex on the north side of Indianapolis 3 large state-of-the-art hospitals 8 critical access hospitals 7 specialty hospitals Numerous joint venture partnerships and clinical affiliations St.Vincent maintains a broad range of specialized areas of expert medical knowledge and practice including cardiovascular, women’s and children’s health, neuroscience, cancer care, orthopedics, bariatric, primary care, emergency medicine, imaging, general surgery, and long-term acute care. And with more than 16,000 associates and 3,000 physicians, St.Vincent has long been one of the largest employers in Indiana. At St.Vincent we’re known for the expertise and compassionate caring provided by our medical staff day in and day out. And our patient-centered approach ensures we remain focused on providing an extraordinary level of service, safety and quality. In all things, we put our patients and their well-being first.