Job Description

Senior Clinical Documentation Improvement Specialist (Exempt) at Mercy summary:

The Senior Clinical Documentation Improvement Specialist is responsible for ensuring the integrity of medical record documentation by reviewing inpatient records and collaborating with clinical providers to obtain missing information. This role includes supporting educational initiatives, performing data analysis, and mentoring lower-level staff to enhance documentation quality. The position requires strong clinical knowledge, excellent communication skills, and the ability to work across various healthcare departments to improve patient care outcomes.

We’re a Little Different

 

Our mission is clear. We bring to life a healing ministry through our compassionate care and exceptional service.

At Mercy, we believe in careers that match the unique gifts of unique individuals – careers that not only make the most of your skills and talents, but also your heart. Join us and discover why Modern Healthcare Magazine named us in its “Top 100 Places to Work.”

Overview:

• This position is an advanced CDI role.
• The Senior Clinical Documentation Specialist coworker is responsible for assisting in the overall integrity of the medical record documentation primarily by conducting reviews of inpatient medical records to identify missing, vague, and/or incomplete components; communicates the need for additional documentation to the appropriate clinical provider and/or coding; ensures the additional documentation is completed in a timely manner; works collaboratively other departments including coding, quality, compliance, the medical staff, utilization review/case management, and any other applicable departments to improve the quality of provider documentation; supports initiatives to improve the quality of documentation by all caregivers.
• This position provides data reports and educational support for required documentation elements to inpatient healthcare providers.
• Performs duties and responsibilities in a manner consistent with our mission, values, and Mercy Service Standards.

Qualifications:

• Minimum Required Qualifications: Education:RN, BSN, RHIA, RHIT, CCS, CPC, CIC, CCDS, or CDIP
• Experience:3 years CDI experience and 1 year in nursing, inpatient coding, UM, CM, Quality, or related field
• Other Skills and Knowledge
  • Demonstrates proficiency of the Clinical Documentation Specialist role
  • Detailed data analysis, ability to present complex data or education to providers individually or in front of a group
  • Excellent critical thinking skills with the ability to quickly make decisive decisions from limited written and/or oral information, excellent reading comprehension
  • Strong clinical knowledge and ability to identify diagnoses based on clinical data
  • Extensive knowledge of disease processes and clinical outcomes.
  • Experience with computer programs (EXCEL, Word, PowerPoint)
  • Advanced knowledge of healthcare regulations, including reimbursement, documentation requirements, and quality measures
  • Skilled in record review with ability to interpret clinical data
  • Assist in special projects and committees Excellent communication skills (written and verbally) and comfortable speaking in groups.
  • Ability to plan and organize work flow in order to meet deadlines
  • Must have strong computer skills including typing ability.
  • Ability to produce reports using multi-formats and software
  • Ability to interpret various data reports and present data findings / report to medical staff committees as needed
  • Ability to establish cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines and interact with all levels of employees
  • Ability to mentor lower-level CDI Specialists
  • Ability to work flexible work schedules to accommodate provider rounding schedules and required medical staff presentations
  • Ability to work with minimum supervision; organizational and administrative skills; function in a stressful environment; encourage and assist with team building; and the ability to maintain the confidentiality of sensitive information, both patient and employee
  • Preferred Qualifications: Education:RN, BSN, RHIA, RHIT, CCS, CPC, CIC
  • Experience:3-5 years CDI experience
  • Certification/Registration: CCDS (Certified Clinical Documentation Specialist) from ACDIS or CDIP (Certified Documentation Improvement Practitioner) from AHIMA preferredOther Skills and Knowledge:

We Offer Great Benefits:

Day-one comprehensive health, vision and dental coverage, PTO, tuition reimbursement and employer-matched retirement funds are just a few of the great benefits offered to eligible co-workers, including those working 32 hours or more per pay period!

 

We’re bringing to life a healing ministry through compassionate care.

At Mercy, our supportive community will be behind you every step of your day, especially the tough ones. You will have opportunities to pioneer new models of care and transform the health care experience through advanced technology and innovative procedures. We’re expanding to help our communities grow. Join us and be a part of it all.

What Makes You a Good Match for Mercy?

Compassion and professionalism go hand-in-hand with us. Having a positive outlook and a strong sense of advocacy is in perfect step with our mission and vision. We’re also collaborative and unafraid to do a little extra to deliver excellent care – that’s just part of our commitment. If that sounds like a good fit for you, we encourage you to apply.

 

 

 

EEO/AA/Minorities/Females/Disabled/Veterans

CDI, clinical documentation specialist, nursing, coding

Keywords:

Clinical Documentation Improvement, CDI Specialist, Healthcare Documentation, Medical Records, Nursing, Coding, Patient Care, Healthcare Quality, Clinical Analysis, Documentation Standards

Job Tags

Flexible hours,

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