RN Clinical Documentation Specialist - ST Peters Hospital

Trinity Health • Albany, NY

1d • Hybrid

About The Position

The RN Clinical Documentation Specialist at St. Peter's Hospital utilizes advanced clinical and coding expertise to ensure the integrity of clinical documentation. This role involves reviewing, educating, and consulting to improve the quality, completeness, accuracy, and integrity of medical records. Through interaction with physicians and the healthcare team, the specialist ensures documentation supports code assignment, medical necessity, severity of illness, risk of mortality, and the level of services rendered. The position also involves developing and delivering education to providers and healthcare team members.

Requirements

• Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) OR an Advanced degree in nursing or medical field such as NP/APN or PA.
• Current Registered Nurse License, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) required, licensure as a physician assistant (PA) or Nurse Practitioner/Advanced Practice Nurse (NP/APN) or completion of medical school.
• Excellent communication (verbal and written), interpersonal, collaboration, and relationship-building skills.
• Strong critical thinking skills and ability to integrate knowledge.
• Prioritization and organizational skills required.
• Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team.
• Demonstrated ability to use a standard desktop and Windows based computer system, including a basic understanding of email, internet, and computer navigation.
• Ability to use other software as required to perform the essential functions on the job.
• Accurate data entry skills and typing skills at minimum 30 wpm.
• Must be comfortable operating independently and in a collaborative environment.
• Must possess a personal presence characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others.
• Ability to comply with Trinity Health policies and procedures.
• Must be able to spend majority of work time utilizing a computer, monitor, and keyboard.
• Must be able to work with interruptions and perform detailed tasks.
• Ability to concentrate and read for long periods of time.

Nice To Haves

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred.
• Two (2) years experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate or as an inpatient coder preferred.
• Experience with databases, spreadsheet software, and presentation software preferred.

Responsibilities

• Utilizes advanced clinical and coding expertise to ensure the integrity of clinical documentation.
• Facilitates the overall quality, completeness, accuracy, and integrity of medical record documentation through extensive record review.
• Achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality, and level of services rendered through interaction with physicians and the healthcare team.
• Participates in the development and delivery of education for providers and members of the healthcare team.
• Ensures the severity of illness, risk of mortality, and level of services provided are accurately reflected in the health record.
• Assists in the overall quality, timeliness, and completeness of the health record.
• Serves as a resource for appropriate clinical documentation.
• Communicates with and educates physicians and other members of the healthcare team regarding clinical documentation and monitors provider engagement.
• Identifies learning opportunities for healthcare providers.
• Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency, and precision of clinical documentation.
• Formulates compliant clarifications/queries following documentation integrity procedures.
• Interacts with physicians, nurses, and ancillary staff regarding compliant documentation requirements, clarification/query requests, and educational opportunities.
• Accurately codes all relevant, appropriate, and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR).
• Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities accurately reflects the patient’s clinical status and care.
• Resolves all discrepancies in a courteous manner.
• Demonstrates expertise in problem-solving skills and serves as a professional role model.
• Leverages the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness.
• Performs other duties as assigned by leadership.
• Maintains a working knowledge of applicable Federal, State, and local laws and regulations, accrediting agencies, and Trinity Health's Organizational Integrity Program, Standards of Conduct, and Code of Ethics.

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
• Number of Employees: 501-1,000 employees