Conduct concurrent reviews of inpatient health records to ensure accurate, complete, consistent clinical documentation. Educate physicians and healthcare staff, monitor provider engagement, and formulate compliant documentation queries addressing severity of illness, mortality risk, quality indicators, and level of service. The role also requires applying documentation integrity procedures, strong clinical judgment, communication, prioritization, computer proficiency, and accurate data entry.
Employment Type:Full timeShift:Day ShiftDescription:MercyOne Genesis Full-Time Remote Position (80 Hours Biweekly)
AA degree in Nursing or HIT. In absence of a degree, 3 years' experience as an inpatient coder or a clinical documentation specialist required
AA degree in Nursing or HIT. In absence of a degree, 3 years' experience as an inpatient coder or a clinical documentation specialist required
Essential Functions:
- Knows, understands, incorporates and demonstrates the Trinity Mission, Vision and Values in behaviors, practices, standards policies procedures and decisions.
- Demonstrates understanding of appropriate clinical documentation to ensure the severity of illness, risk of mortality, quality indicators and level of services provided are accurately reflected in the health record.
- Communicates with and educates physicians and all other member of the healthcare team in clinical documentation and monitors provider engagement.
- Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency and precision of clinical documentation.
- Formulates compliant clarifications/queries following Trinity Health's documentation integrity procedures.
Minimum Qualifications:
- Must possess an Associate/Diploma Degree in Health Information Technology (HIT) or Advanced degree in nursing (NP, APN) or Physician Assistant. In absence of college degree, must have three (3) years' experience as an inpatient code or documentation specialist.
- Preferred Certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP
- Experienced in critical care, medical or surgical inpatient care nursing as an RN, PA, NP, APN or inpatient coder preferred
- Excellent communication, interpersonal, collaboration and relationship building skills. Strong critical thinking skills, and ability integrate knowledge. Prioritization and organizations skills required.
- Demonstrated ability to use standardized desktop and Windows based computer system. Data entry and typing skills at minimum 30 wph.
Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
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