RN Clinical Documentation Specialist - ST Peters Hospital

Trinity Health • Albany, NY

8d • $32 - $48

About The Position

The RN Clinical Documentation Specialist uses advanced clinical and coding expertise to support the integrity of clinical documentation as a reviewer, educator, and consultant. Through extensive medical-record review, the specialist promotes the quality, completeness, accuracy, and integrity of documentation. The position works closely with physicians and other healthcare team members to support documentation that appropriately reflects code assignment, medical necessity, severity of illness, risk of mortality, and the level of services rendered. The specialist also participates in developing and delivering education for providers and healthcare team members.

This full-time role is based at St. Peter’s Hospital in Albany, New York, and works day shift. It reports directly to the Regional CDI Manager and has no staff supervisory responsibility. The position may be performed in onsite and virtual environments.

The role requires an associate or diploma degree in nursing or health information technology, or an advanced degree in a nursing or medical field such as NP/APN or PA, along with one of the specified professional licenses, credentials, or qualifications. Preferred qualifications include clinical documentation credentials and two years of relevant inpatient clinical or coding experience.

Requirements

• Associate degree or diploma in Nursing or Health Information Technology, or an advanced degree in a nursing or medical field such as NP/APN or PA.
• Must possess one of the following: current Registered Nurse license; RHIA; RHIT; required Certified Coding Specialist (CCS); licensure as a PA or NP/APN; or completion of medical school.
• Excellent verbal and written communication, interpersonal, collaboration, and relationship-building skills.
• Strong critical-thinking skills and ability to integrate knowledge.
• Prioritization and organizational skills.
• Effective presentation and facilitation skills to support educational goals for healthcare team members.
• Ability to use a standard desktop and Windows-based computer system, including email, internet, and computer navigation, and other software required for the job.
• Accurate data-entry skills and typing speed of at least 30 words per minute.
• Ability to work independently and collaboratively.
• Personal presence characterized by honesty, integrity, and caring, with the ability to inspire and motivate others in support of Trinity Health’s philosophy, mission, vision, goals, and values.
• Ability to organize and reprioritize work as priorities change frequently.
• Ability to work concurrently on varied tasks and projects in a potentially stressful environment with people who have diverse personalities and work styles.
• Ability to comply with Trinity Health policies and procedures.
• Ability to spend most work time using a computer, monitor, and keyboard; work with interruptions; perform detailed tasks; and concentrate and read for extended periods.

Nice To Haves

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP).
• Two years of experience in critical care, medical or surgical inpatient nursing, or work as an RN, PA, NP/APN, medical school graduate, or inpatient coder.
• Experience with databases, spreadsheet software, and presentation software.

Responsibilities

• Demonstrate Trinity Health’s Mission, Vision, and Values in work behaviors, practices, standards, policies, procedures, and decisions.
• Ensure that documentation accurately reflects severity of illness, risk of mortality, and services provided.
• Support the quality, timeliness, and completeness of health records, including appropriate data, provider communication, and quality outcomes.
• Serve as a resource on appropriate clinical documentation and communicate with and educate physicians and other healthcare team members.
• Monitor provider engagement and identify learning opportunities for healthcare providers.
• Conduct concurrent reviews of selected patient health records for legibility, clarity, completeness, consistency, and precision.
• Formulate compliant documentation clarifications and queries according to Trinity Health procedures.
• Work with physicians, nurses, and ancillary staff on compliant documentation requirements, clarification and query requests, and educational opportunities.
• Code relevant, appropriate, and compliant working diagnoses; establish a working principal diagnosis and working DRG (MS or APR).
• Collaborate with coding staff to ensure discharge diagnoses and comorbidities fully reflect the patient’s clinical status and care.
• Resolve discrepancies courteously.
• Apply problem-solving skills based on theoretical knowledge, clinical experience, and sound judgment, and model desirable professional practice behaviors.
• Use 3M/360 functions to enter data related to CDI efficiencies and effectiveness.
• Perform other duties assigned by leadership.
• Maintain working knowledge of applicable laws, regulations, accrediting agency requirements, and Trinity Health integrity, conduct, ethics, policy, and procedure requirements.

Benefits

• Strong orientation program
• Generous tuition allowance
• Career development

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree