Join Our Team as a Clinical Documentation Specialist II! Join TriHealth as a Clinical Documentation Specialist II and partner with interdisciplinary teams to improve documentation accuracy, support quality outcomes, and elevate patient care. Apply today and be part of a team that is passionate about making a difference. We offer career growth opportunities, and a comprehensive benefits package. Location: Work Schedule: Incentives & Benefits: We offer a comprehensive benefits package, including medical, dental, vision, paid time off, retirement plans, and tuition reimbursement. https://careers.trihealth.com/what-we-offer/benefits Job Requirements: Bachelor's Degree in Nursing; Business, Education, HIM, CCDS - Certified Clinical Documentation Specialist Registered Nurse Advanced CDI certification if available Computer aptitude including but not limited to electronic medical record clinical documentation software programs, Word, Excel and PowerPoint 5-7 years experience Clinical Nursing 2-3 years experience Clinical Documentation
Job Overview: - The Clinical Documentation Specialist II reports to the Clinical Documentation Department Manager. This team member assists with the delivery of clinical documentation strategies within the workplace that positively impact and drive change to attain organizational goals as well as maintain documentation standards as set by government and corporate guidelines, The Clinical Documentation Specialist II requires an advanced level of knowledge and experience for the successful management of clinical education in their specialty area, quality monitoring, documentation review and the ability to communicate this knowledge to team members throughout the organization, including Medical Staff Departments. They will serve as a subject matter experts in their specialty field which includes but is not limited to preparing and presenting a minimum of two educational topics each calendar year for the benefit of the medical staff, APNs, residents and/or team members as well as being responsible for specialty specific orientation to new team members or those who need refreshers. They will participate in peer interviews and leadership opportunities such as serving on committees, leading journal club or conducting a review course for team members interested in certification. This position requires a professional who works well independently but also values team and possesses excellent communication skills.
Job Responsibilities: Documentation Improvement - record review rate of at least 98%. Severity clarification rate of at least 25%. DRG shift clarification rate of at least 15%.
Provides Informal education includes sharing with team members in assigned patient care area, inpatient coding department and clinical documentation team advanced or new strategies for capturing highest level of SOI/ROM, denial prevention, and determining PSIs. Documentation of informal education with physicians, APNs, residents on documentation strategies and their importance.
Participates in department or hospital committees such as Stroke Committee, Task Force, etc., new team member specialty orientation leader or participating as part of the peer interview team. Other options include but are not limited to leading a department journal club or participating in a minimum of 10 hours of approved community service per year.
Other Job-Related Information: This position requires excellent verbal and written communication skills as well as proficiency in the electronic medical record, clinical documentation software, word, excel and power point. Expectation is that the Clinical Documentation Specialist 2 will prepare a minimum of two educational topics to be shared with team members at staff meetings and/or physicians at staff meetings on topics related to advanced CDI. Working Conditions:
Climbing - Occasionally
Concentrating - Consistently
Continous Learning - Consistently
Hearing: Conversation - Occasionally
Interpersonal Communication - Consistently
Kneeling - Occasionally
Lifting <10 Lbs - Occasionally
Lifting 50+ Lbs - Rarely
Lifting 11-50 Lbs - Occasionally
Pulling - Occasionally
Pushing - Frequently
Reaching - Frequently
Reading - Consistently
Sitting - Frequently
Standing - Frequently
Stooping - Occasionally
Thinking/Reasoning - Consistently
Use of Hands - Consistently
Color Vision - Consistently
Walking - Frequently TriHealth SERVE Standards and ALWAYS Behaviors:
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:
Serve: ALWAYS…
• Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
• Refrain from using cell phones for personal reasons in public spaces or patient care areas
Excel: ALWAYS…
• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
• Offer patients and guests priority when waiting (lines, elevators)
• Work on improving quality, safety, and service
Respect: ALWAYS…
• Respect cultural and spiritual differences and honor individual preferences.
• Respect everyone’s opinion and contribution, regardless of title/role.
• Speak positively about my team members and other departments in front of patients and guests.
Value: ALWAYS…
• Value the time of others by striving to be on time, prepared and actively participating.
• Pick up trash, ensuring the physical environment is clean and safe.
• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.
Engage: ALWAYS…
• Acknowledge wins and frequently thank team members and others for contributions.
• Show courtesy and compassion with customers, team members and the community
Job Keywords: Registered Nurse, Nurse, Clinical Documentation |
