Clinical Documentation Specialist II

TriHealth • Cincinnati, OH

6d

About The Position

The Clinical Documentation Specialist II reports to the Clinical Documentation
Department Manager. This team member assists with the delivery of clinical
documentation strategies within the workplace that positively impact and drive
change to attain organizational goals as well as maintain documentation
standards as set by government and corporate guidelines,The Clinical
Documentation Specialist II requries an advanced level of knowledge and
experience for the successful management of clinical education in their
specialty area, quality monitoring, documentation review and the ability to
communicate this knowledge to team members throughout the organization,
including Medical Staff Departments. They will serve as a subject matter experts
in their specialty field which includes but is not limited to preparing and
presenting a minimum of two educational topics each calendar year for the
benefit of the medical staff, APNs, residents and/or team members as well as
being responsible for specialty specific orientation to new team members or
those who need refreshers. They will participate in peer interveiws and
leadership opportunities such as serving on committees, leading journal club or
conducting a review course for team members interested in certification. This
position requires a professional who works well independently but also values
team, and possesses excellent communication skills.

Requirements

• Bachelor's Degree in Nursing; Business, Education, HIM,
• CCDS - Certified Clinical Documentation Specialist,
• Registered Nurse
• Advanced CDI certification if available
• Computer aptitude including but not limited to Electronic medical record Clinical documentation software programs, Word, Excel and PowerPoint
• 5-7 years experience Clinical Nursing
• 2-3 years experience Clinical Documentation

Responsibilities

• Documentation Improvement - record review rate of at least 98%. Severity clarification rate of at least 25%. DRG shift clarification rate of at least 15%.
• Provides Informal education includes sharing with team members in assigned patient care area, inpatient coding department and clinical documentation team advanced or new strategies for capturing highest level of SOI/ROM, denial prevention, and determining PSIs.Documentation of informal education with physicians, APNs, residents on documentation strategies and their importance.
• Maintains specialty certification and pursue advanced CDI certification within 1 year of certification becoming available. A minimum of two formal presentations per year on pertinent advanced CDI topics at monthly team meetings, resident or medical staff meetings.
• Participates in department or hospital committee such as Stroke Committee, Task Force, etc., new team member specialty orientation leader or participating as part of the peer interview team. Other options include but are not limited to leading a department journal club, or participating in a minimum of 10 hours of approved community service per year.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1,001-5,000 employees