T

CDI RN Clinical Documentation Specialist Registered Nurse

Trinity Health
Full-time
On-site
Sioux City, Iowa, United States

Employment Opportunities At MercyOne

At MercyOne, health care is more than just a doctor's visit or a place to go when you're in need of medical attention. Our mission is based on improving the health of our communities that means not only when you are sick but keeping you well. MercyOne Siouxland Medical Center has earned more national recognition for quality patient outcomes than any other hospital in the region. The medical center has earned multiple honors for its leadership and excellence in several clinical areas including cardiac care, orthopedic services, vascular surgery, stroke care, and cancer care.

Join the MercyOne Family! We are looking to hire a Registered Nurse (RN). As an RN at MercyOne, you will recognize and understand the legal boundaries for practicing nursing within the scope of nursing practice. Per the Iowa Board of Nursing, the scope of practice of the registered nurse is determined by the nurse's education, experience, and competency and the rules governing nursing. Nursing integrates the art and science of caring and focuses on the protection, promotion, and optimization of health and human functioning; prevention of illness and injury; facilitation of healing; and alleviation of suffering through compassionate presence.

Schedule: Full time, 40 hours per week, no weekends or holidays.

General Requirements:

  • Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, standards, policies, and decisions.
  • Demonstrates understanding of appropriate clinical documentation to ensure that the severity of illness, risk of mortality, quality indicators, and level of services provided are accurately reflected in the health record. Assists in overall quality, timeliness, and completeness of the health record to ensure appropriate data, provider communication, and quality outcomes. Serves as a resource for appropriate clinical documentation.
  • Communicates with and educates physicians and all other members of the healthcare team regarding clinical documentation and monitors provider engagement. Identifies learning opportunities for healthcare providers.
  • Conducts concurrent reviews of selected patient health records to address legibility, clarity, completeness, consistency, and precision of clinical documentation.
  • Formulates compliant clarifications/queries following Trinity Health's documentation integrity procedures.
  • Interacts with physicians, nurses, and ancillary staff regarding compliant documentation requirements, clarification/query requests, and educational opportunities.
  • Codes all relevant, appropriate, and compliant working diagnoses codes, establishing a working principle diagnosis and working DRG (MS or APR).
  • Collaborates with coding staff to ensure documentation of discharge diagnoses and co-morbidities are a complete reflection of the patient's clinical status and care. Resolves all discrepancies in a courteous manner.
  • Demonstrates expertise in problem-solving skills based on theoretical knowledge, clinical experience, and sound judgment and serves as a professional role model by demonstrating desirable practice behaviors.
  • Leverages the functions of 3M/360 for entering data related to CDI efficiencies and effectiveness.
  • Performs other duties as assigned by leadership.
  • Maintains a 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, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.

Minimum Qualifications:

  • Is a registered nurse maintaining current licensure defined by Interstate Compact. A senior level nursing student of an accredited nursing program may apply.
  • BSN preferred.
  • Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), medical school graduate, or as an inpatient coder preferred.
  • Maintains a high level of professionalism, which positively promotes the image of Mercy Medical Center.
  • Actively participates and represents Mercy Medical Center in professional and community organizations.
  • Must possess excellent verbal and written communications skills, presentation skills, advanced analytical skills, be well organized, and maintain a highly professional manner and appearance.
  • Strong interpersonal, consultative, and relationship-building skills in order to initiate and develop productive collaborative partnerships with all levels of leadership across the organization. Ability to effectively influence results, garner support, and tactfully manage complex relationships within and across the organization. Extremely high level of diplomacy and tact are required. Ability to read the subtle nuances of situation and react/plan accordingly.
  • Must be comfortable operating in a collaborative, shared leadership environment.
  • Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.

Colleagues of MercyOne Health System enjoy competitive compensation with a full benefits package and opportunity for growth throughout the system!

Apply now
Share this job