Job Description

Find your calling at Mercy!

The Clinical Documentation Specialist provides clinically based, concurrent and retrospective reviews of inpatient medical records. Will work to identify opportunities and ensure accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes. This position collaborates with inpatient care providers to ensure accurate, complete, compliant, concise, and consistent documentation that reflects the true clinical scenario of the patient’s encounter. This additionally serves to reflect the true Severity of Illness (SOI), Risk of Mortality (ROM), and intensity of services rendered to provide quality care and treatment to the patient.
Performs duties and responsibilities in a manner consistent with our mission, values, and Mercy Service Standards.

Position Details:

Minimum Required Qualifications
Education:
RN, BSN, RHIA, RHIT, CCS, CPC, CIC, CCDS, or CDIP 

Experience:
1-year related experience in acute care inpatient nursing or inpatient coding or HIM 

Other Skills and Knowledge:
• Excellent critical thinking skills with the ability to quickly make decisive decisions from limited written and/or verbal information, excellent reading comprehension
• Excellent communication skills (written and verbally) and comfortable speaking in groups.
• Ability to plan and organize workflow in order to meet deadlines
• Must have strong computer skills including typing ability.
• Experience with computer programs (EXCEL, Word)
• Data entry
• Record review with ability to interpret clinical data
• Strong clinical knowledge
• 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 work flexible work schedules to accommodate provider rounding schedules and required medical staff presentations
• Employee should possess: the 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
• Detail oriented
• Ability to work independently

Preferred Qualifications
Education:
RN, CCS, CPC, RHIA, RHIT, or a combination thereof
Experience: 
3 years nursing, inpatient coding, or other HIM role in acute hospital setting
Knowledge of diagnosis-related groups (DRG), prospective payment systems, and hospital quality performance initiative. 
Utilization review/case management experience

Certification/Registration: CCDS (Certified Clinical Documentation Specialist) from ACDIS or CDIP (Certified Documentation Improvement Practitioner) from AHIMA preferred
Other Skills and Knowledge:

Why Mercy?

From day one, Mercy offers outstanding benefits - including medical, dental, and vision coverage, paid time off, tuition support, and matched retirement plans for team members working 32+ hours per pay period.

Join a caring, collaborative team where your voice matters. At Mercy, you'll help shape the future of healthcare through innovation, technology, and compassion. As we grow, you'll grow with us.

Job Tags

Similar Jobs