RN Clinical Documentation Specialist - ST Peters Hospital
St. Peter's Health Partners, Albany, New York, United States
Overview
Recognized leader: Magnet Hospital in the Capital Region Quality of Life: Where career opportunities and quality of life converge Advancement: Strong orientation program, generous tuition allowance and career development Employment
Full time Shift
Day Shift Description
RN Clinical Documentation Specialist — Full-time day shift — St. Peter's Hospital in Albany, NY Position Highlights
Recognized leader: Magnet Hospital in the Capital Region Quality of Life: Where career opportunities and quality of life converge Advancement: Strong orientation program, generous tuition allowance and career development What You Will Do
The Clinical Documentation Specialist utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review. Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team. Primary Job Responsibilities And Duties
Know, understand, incorporate, and demonstrate the Trinity Health Mission, Vision, and Values in behaviors, practices, standards, policies, procedures and decisions. Demonstrate understanding of appropriate clinical documentation to ensure severity of illness, risk of mortality and level of services provided are accurately reflected in the health record. Assist in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes. Serve as a resource for appropriate clinical documentation; communicate with and educate physicians and all healthcare team members regarding clinical documentation and monitor provider engagement. Identify learning opportunities for healthcare providers. Conduct concurrent reviews of selected patient health records addressing legibility, clarity, completeness, consistency and precision of clinical documentation. Formulate compliant clarifications/queries following Trinity Health’s documentation integrity procedures. Interact with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification/query requests and educational opportunities. Accurately code relevant, appropriate and compliant working diagnoses codes, establishing a working principal diagnosis and working DRG (MS or APR). Collaborate with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care. Resolve all discrepancies in a courteous manner. Demonstrate problem-solving skills based on theoretical knowledge, clinical experience and sound judgement; serve as a professional role model with desirable practice behaviors. Proficient with leveraging the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness. Perform other duties as assigned by leadership. Maintain working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics, and other policies and procedures to ensure ethical and professional behavior. Minimum Qualifications, Required Knowledge, Skills And Abilities
Must possess an 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. Must Possess One Of The Below 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 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, PA, NP/APN, medical school graduate or inpatient coder preferred 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 standard desktop and Windows-based computer systems, including basic email, internet and computer navigation. Ability to use other software as required to perform essential functions. Experience with databases, spreadsheet software and presentation software preferred. 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 honesty, integrity and caring with the ability to inspire and motivate others to promote Trinity Health's mission, vision, values. Physical And Mental Requirements And Working Conditions
Must be able to set and organize own work priorities and adapt to changing priorities. Must be able to work concurrently on a variety of tasks in a potentially stressful environment with diverse personalities and work styles. Must possess the ability to comply with Trinity Health policies and procedures. Must be able to spend the majority of time using a computer, monitor and keyboard. Must be able to work with interruptions and perform detailed tasks. The position requires concentration and the ability to read for long periods. Ability to work in an onsite and virtual environment. Reporting Relationships
Reports directly to the Regional CDI Manager. Has no responsibility for the supervision of staff. Pay Range
$31.50 - $47.97 Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location. 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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Recognized leader: Magnet Hospital in the Capital Region Quality of Life: Where career opportunities and quality of life converge Advancement: Strong orientation program, generous tuition allowance and career development Employment
Full time Shift
Day Shift Description
RN Clinical Documentation Specialist — Full-time day shift — St. Peter's Hospital in Albany, NY Position Highlights
Recognized leader: Magnet Hospital in the Capital Region Quality of Life: Where career opportunities and quality of life converge Advancement: Strong orientation program, generous tuition allowance and career development What You Will Do
The Clinical Documentation Specialist utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review. Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team. Primary Job Responsibilities And Duties
Know, understand, incorporate, and demonstrate the Trinity Health Mission, Vision, and Values in behaviors, practices, standards, policies, procedures and decisions. Demonstrate understanding of appropriate clinical documentation to ensure severity of illness, risk of mortality and level of services provided are accurately reflected in the health record. Assist in overall quality, timeliness and completeness of the health record to ensure appropriate data, provider communication and quality outcomes. Serve as a resource for appropriate clinical documentation; communicate with and educate physicians and all healthcare team members regarding clinical documentation and monitor provider engagement. Identify learning opportunities for healthcare providers. Conduct concurrent reviews of selected patient health records addressing legibility, clarity, completeness, consistency and precision of clinical documentation. Formulate compliant clarifications/queries following Trinity Health’s documentation integrity procedures. Interact with physicians, nurses and ancillary staff regarding compliant documentation requirements, clarification/query requests and educational opportunities. Accurately code relevant, appropriate and compliant working diagnoses codes, establishing a working principal diagnosis and working DRG (MS or APR). Collaborate with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient’s clinical status and care. Resolve all discrepancies in a courteous manner. Demonstrate problem-solving skills based on theoretical knowledge, clinical experience and sound judgement; serve as a professional role model with desirable practice behaviors. Proficient with leveraging the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness. Perform other duties as assigned by leadership. Maintain working knowledge of applicable Federal, State and local laws and regulations, accrediting agencies, Trinity Health’s Organizational Integrity Program, Standards of Conduct, Code of Ethics, and other policies and procedures to ensure ethical and professional behavior. Minimum Qualifications, Required Knowledge, Skills And Abilities
Must possess an 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. Must Possess One Of The Below 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 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, PA, NP/APN, medical school graduate or inpatient coder preferred 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 standard desktop and Windows-based computer systems, including basic email, internet and computer navigation. Ability to use other software as required to perform essential functions. Experience with databases, spreadsheet software and presentation software preferred. 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 honesty, integrity and caring with the ability to inspire and motivate others to promote Trinity Health's mission, vision, values. Physical And Mental Requirements And Working Conditions
Must be able to set and organize own work priorities and adapt to changing priorities. Must be able to work concurrently on a variety of tasks in a potentially stressful environment with diverse personalities and work styles. Must possess the ability to comply with Trinity Health policies and procedures. Must be able to spend the majority of time using a computer, monitor and keyboard. Must be able to work with interruptions and perform detailed tasks. The position requires concentration and the ability to read for long periods. Ability to work in an onsite and virtual environment. Reporting Relationships
Reports directly to the Regional CDI Manager. Has no responsibility for the supervision of staff. Pay Range
$31.50 - $47.97 Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location. 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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