UnityPoint Health

  • Clinical Documentation Specialist

    Requisition ID
    2018-46743
    Category
    Quality
    Location
    US-IL-Rock Island
    Address
    2701 17th St
    Affiliate
    6020 UnityPoint Health QC Trinity
    City
    Rock Island
    Department
    Clinical Documentation
    State
    IL
    FTE
    0.8
    FLSA
    Exempt
    Scheduled Hours/Shift
    Days, no weekends. Possible to work remotely following 8 week training
  • Overview

    Clinical Documentation Specialist RN, 0.8 FTE exempt, Days, can be remote after orientation, but must reside within approximately 1 hour driving distance of the Rock Island, IL hospital for orientation, trainings, and meetings. UnityPoint Health affiliate employees living farther will be considered, but must still be within driving distance for orientation and trainings. Current licensure in Illinois and Iowa required. Three to five years clinical experience in acute care, intermediate care or home care required.  An internet-based exam is required and must be passed as a part of the screening process. Responsible for concurrent and retrospective review of selected inpatient medical records to facilitate complete and accurate documentation of patient conditions, diagnoses, and procedures. Communicates with physicians and providers to clarify clinical documentation to accurately reflect severity of illness, risk or mortality, and intensity of services provided. Identifies diagnostic and procedure codes through use of established coding guidelines. Promotes communication and collaboration among all members of the health care team.

     

    UnityPoint Health team members come for a job, but stay for a career. As a team member, you'll get the chance to change lives on a daily basis in order to deliver the Best Outcome Every Patient, Every Time- regardless of your position. That privilege drives employees' passion for making a difference in the lives of our patients, helping them create healthier, more rewarding lives. UnityPoint Health sets high expectations for team members in order to establish a trusted team capable of taking on the toughest of challenges.

    Responsibilities

    TECHNICAL/ADMINISTRATIVE/CLINICAL:

    Demonstrates competence in the skills, (processes, procedures, and equipment) necessary to carry out assigned duties as identified below.

     

    1. Perform and document initial and concurrent review of medical record to identify existing conditions, complications and/or comorbid conditions.
    2. Recognize opportunities for documentation improvement and formulate clinically credible clarifications for the physician or provider. 
    3. Build relationships with the physicians and hospital staff to promote open communication and education regarding complete, accurate, and timely documentation in the medical record. 
    4. Improve documentation by serving as a resource and educating physicians, clinicians and other involved parties regarding the necessity or complete and clear documentation in the patient record. 
    5. Remain current with coding information to ensure accuracy of codes assigned based on documentation. 
    6. Participate in educational programs and inservices to maintain excellent skills. 
    7. Collaborate with HIM and coding staff to facilitate complete and accurate documentation and coding of the inpatient record. 
    8. Collaborate with hospital staff to ensure that required documentation is completed for core measures and patient safety indicators.

     

    DEMONSTRATION OF VALUES:  

    Consistently demonstrates Trinity’s values in the performance of job duties and  responsibilities.

    1. Demonstrates all standards of ACES standards of behavior to patient’s, associates, physicians and co-workers.
    2. Demonstrates Excellence – A standard of the highest quality in the service we deliver to meet the various needs of our customers.
    3. Demonstrates Flexibility – An openness to the change which accompanies the exploration of new ways of delivering service.
    4. Demonstrates Integrity – The assurance that all our dealings with patients and their families, physicians, employees, suppliers, and the community members and others with whom we do business, will be filled with respect, fairness and honesty.
    5. Demonstrates Responsiveness – A commitment to work with others to identify the needs of our customers and to strive to meet these needs.
    6. Demonstrates Service – A pledge to offer appropriate services to all persons, regardless of socioeconomic status, race or religion.
    7. Demonstrates Teamwork – A cooperative effort, involving employees, physicians, patients, and community members, working together to provide quality, compassionate, cost-effective health care.

     

    PRINCIPLES OF HOSPITALITY: Consistently demonstrates  Trinity’s co-workers, visitors, and others.

     

    1. Uses the A.I.D.E.T. healing language of service always.
    2. Is friendly.                                                                                               
    3. Responds quickly.                                                                        
    4. Takes ownership.                                                                         
    5. Is a valued information resource.                                                 
    6. Shows respect for others.                                                             
    7. Provides value-added service. 
    8. Projects a professional image.                    

    WORKING CONDITIONS:

    • May be exposed to infections or contagious diseases (Category II)
    • Occasional exposure to unpleasant patient or unit elements
    • Occasionally subjected to irregular hours.
    • May work under tight time constraints to meet deadlines.
    • Occasional pressure due to multiple calls and inquiries.
    • May be required to travel to and work at other Trinity sites.
    • Extensive computer use and exposure to video display terminal.
    • Smoke free environment. 
    • PHYSICAL DEMANDS:
    •  
    • Light physical effort (lift/carry up to 10 lbs)
    • Occasional prolonged sitting, standing or walking
    • Occasionally lifts, positions, pushes and/or pulls supplies/equipment
    • Manual dexterity and mobility
    • Occasional reaching, stooping, bending, kneeling, crouching
    • Requires hearing ability for normal conversations
    • Requires near acuity: ability to see clearly at 20 inches or less

    Qualifications

     

    EDUCATION, TRAINING & EXPERIENCE: RN required. BSN or equivalent advanced degree preferred.   Three to five years clinical experience in acute care, intermediate care or home care required.   Utilization review, case management, and/or coding experience preferred.  

     

    KNOWLEDGE, ABILITIES & SKILLS: Knowledge of Medicare regulations and   hospital documentation requirements. Knowledge of pathophysiology, clinical issues, and disease processes. Effective verbal and written communication skills. Effective interpersonal skills to establish strong working relationships with all members of the health care team. Organizational, analytical, and critical thinking skills.   Self-directed with ability to work with minimal supervision in an outcome oriented environment. Proficiency with key board skills, electronic documentation, various software, and computer use.

     

             LICENSES, REGISTRATIONS AND CERTIFICATIONS: RN's must hold a 

             current licensure by the Illinois and Iowa State Board of Nursing Examiners.

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