Everyone who works with Mercy Health is united under one purpose: to help our patients be well in mind, body and spirit. This drive, along with our history of faith, is a powerful combination. It gives us a shared calling to work toward every day. Join our exceptional team and help us continue to provide the highest quality of health care possible to our communities.

Mercy Health St. Vincent

Essential Functions:

• Facilitates appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record

• Performs admission reviews for specific patient populations using clinical documentation guidelines

• Assists in medical screening process by documenting appropriateness of patient admission, working DRG & LOS info on worksheet and computer system as appropriate

• Extensively reviews all physician and clinical documentation, lab results, diagnostic information, and treatment plans and captures appropriate information on CDMP® worksheet

• Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, acuity and resource consumption

• Verbally communicates with appropriate physician(s) to ensure documentation opportunities are clarified

• Communicates with ancillary personnel (e.g., PT, ET) to clarify potential documentation opportunities

• Updates DRG worksheet to reflect any changes in patient status, procedures/treatments, and confers with physician to finalize diagnoses.

• Reviews medical record every 24-48 hours as appropriate

• Updates Clinical Documentation Management Program worksheet to reflect additional physician documentation, lab findings, diagnostic test results and treatment as appropriate

• Updates Clinical Documentation Management Program worksheet to reflect any changes in DRG assignment

• Communicates with physician to ensure that request for documentation has been noted

• Confers with physician to establish appropriate severity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures

• Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in patient’s chart

• As appropriate, documents, analyzes data and reports instances of inappropriate patient care, discharge delays, etc. to Manager of Health Records Services

• Collaborates with coding staff as needed to determine appropriate DRG and required documentation

• Stays current with and conducts on-going clinical documentation management program education for new staff, including new clinical documentation specialists, physicians and nursing and allied health professionals. Tracks and trends program compliance

• Participates in concurrent performance improvement activities and on-going MR review activities

• Maintains positive and open communications with physicians, interdisciplinary care team members, coding staff, Regional Manager of Coding, Quality and Compliance

Qualifications:

• Registered Nurse (RN) with 5+ years of experience in Med/Surg, Critical Care, ICU, or ED experience required

• Active RN license in Ohio or Kentucky required

• Certified Clinical Documentation Specialist (CCDS) preferred

• 70% or greater on JA Thomas's Clinical Competency Assessment required

• Excellent interpersonal skills including verbal and written communication skills required as well as the ability to demonstrate excellent physician relations

Schedule:

• Full-Time position at 40 hours/week from 8:00am to 4:30pm EST

• Rotational Saturday shift required

Many of our opportunities reward* your hard work with:

Comprehensive, affordable medical, dental and vision plans
Prescription drug coverage
Flexible spending accounts
Life insurance w/AD&D
Employer contributions to retirement savings plan when eligible
Paid time off
Educational Assistance
And much more

• Benefits offerings vary according to employment status

All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email recruitment@mercy.com. If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com