1,395 Clinical Documentation jobs in the United States
Clinical Documentation Specialist
Posted 1 day ago
Job Viewed
Job Description
**PEOPLE ESSENTIAL FUNCTIONS**
+ Improves the overall quality, completeness and accuracy of clinical documentation by performing open record reviews using clinical documentation guidelines. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical outcomes.
**SERVICE ESSENTIAL FUNCTIONS**
+ Seeks additional information regarding clinical condition from appropriate clinical personnel and follows up as necessary. Tracks responses and trends completion of DRG/Documentation worksheets as pertinent to scope of department.
+ Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.
**QUALITY/SAFETY ESSENTIAL FUNCTIONS**
+ Demonstrates knowledge of DRG payor issues, optimization strategies, clinical documentation requirements and referral policies and procedures. Requests clarification and/or correction from physicians for unclear diagnoses, complications, procedures, and clinical information. Helps identify appropriate ICD10 codes for diagnoses or procedures related to projects or studies being conducted as needed.
**FINANCE ESSENTIAL FUNCTIONS**
+ Promotes clarification to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients. Identifies diagnoses and procedures performed and comorbidities and complications. Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis as necessary.
**GROWTH/INNOVATION ESSENTIAL FUNCTIONS**
+ Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies
This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
**EDUCATION**
+ Associate's or bachelor's degree in nursing; OR
+ Medical School graduate where Western Medicine is practiced
**WORK EXPERIENCE**
+ For RN - At least five years of recent clinical experience caring for adults in an acute care hospital setting is required; coding and utilization review experience preferred
+ For Medical School graduate - One year of clinical experience preferred
**LICENSES AND CERTIFICATIONS - REQUIRED**
+ RN - Registered Nurse - Texas State Licensure and/or Compact State Licensure within 60 days **OR**
+ RN-Temp - Registered Nurse - Temporary State Licensure within 60 days
+ CCDS - Clinical Documentation Specialists (ASDIS) -- For Medical School graduate **OR**
+ CDIP - Certified Documentation Integrity Practitioner (AHIMA) -- For Medical School graduate **OR**
+ CCS - Certified Coding Specialist (AHIMA) -- For Medical School graduate
**KNOWLEDGE, SKILLS, AND ABILITIES**
+ Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
+ Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
+ Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
+ Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
+ Demonstrates accountability and professional development
+ Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
+ Regular significant contacts with other personnel throughout the institution (including but not limited to - physicians and their staff, mid-level providers, mid-level staff, coders, Case Managers). Contacts may be in person, by telephone, or through correspondence. Requires assertiveness while being even tempered, with a pleasing personality and the ability to communicate easily with others.
**SUPPLEMENTAL REQUIREMENTS**
**WORK ATTIRE**
+ Uniform No
+ Scrubs No
+ Business professional Yes
+ Other (department approved) No
**ON-CALL***
_*Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below._
+ On Call* No
**TRAVEL***
_**Travel specifications may vary by department**_
+ May require travel within the Houston Metropolitan area No
+ May require travel outside Houston Metropolitan area No
**Company Profile:**
Houston Methodist is one of the nation's leading health systems and academic medical centers. Houston Methodist consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the heart of the Texas Medical Center, and seven community hospitals throughout the greater Houston area. Houston Methodist also includes an academic institute, a comprehensive residency program, a global business division, numerous physician practices and several free-standing emergency rooms and outpatient facilities. Overall, Houston Methodist employs more than 27,000 employees and is supported by a wide variety of business functions that operate at the system level to help enable clinical departments to provide high quality patient care.
Houston Methodist is an Equal Opportunity Employer.
Clinical Documentation Specialist
Posted 1 day ago
Job Viewed
Job Description
The Clinical Documentation Specialist (CDS) performs clinical documentation improvement (CDI) activities to support the accuracy, quality, and completeness of patient records at facilities. This role ensures that coded diagnoses and procedures reflect the patient's clinical status and care provided. The CDS collaborates with providers through education and the physician query process, ensuring medical records accurately reflect patient severity of illness and support continuity of care, appropriate quality metrics, and regulatory compliance.
**Essential Functions**
+ Analyzes inpatient clinical records to identify opportunities for improving documentation accuracy, ensuring assigned codes reflect patient severity and acuity.
+ Adheres to corporate recommended CDI workflows and uses CDI and medical records software, such as 3M 360 Encompass and Iodine Interact, to support documentation practices.
+ Utilizes approved physician query processes to clarify documentation, ensuring queries are compliant, necessary, and non-leading, and follows up daily on unanswered queries.
+ Conducts follow-up reviews of patient records to identify new documentation opportunities and ensures accuracy through continuous review.
+ Tracks CDI activities within CDI software, accurately reporting impact metrics and maintaining clear records of all interactions and documentation efforts.
+ Provides education and training to providers, explaining recommendations for documentation improvement and offering insights through individual or group sessions.
+ Collaborates closely with coding professionals to ensure accurate diagnostic and procedural data through complete and compliant documentation.
+ Leads physician education initiatives, developing strategies to improve documentation practices at the facility level and conducting formal training sessions.
+ Monitors regulatory changes in coding, documentation, and quality metrics, ensuring compliance with updated standards and sharing information with staff as needed.
+ Creates and submits accurate reports in a timely manner, maintaining up-to-date knowledge of best practices and industry standards to support CDI goals.
+ Performs other duties as assigned.
+ Complies with all policies and standards.
**Qualifications**
+ Associate Degree in Nursing, Health Information Management, or a related field required
+ Bachelor's Degree in Nursing, Health Information Management, or a related field preferred
+ 4-6 years of acute care hospital nursing experience (e.g. medical/surgical unit, intensive care) required
+ 3-5 years of experience in clinical documentation improvement, health information management, or inpatient coding preferred
+ Experience in physician education or query processes preferred
+ Familiarity with regulatory standards and quality metrics related to clinical documentation preferred
**Knowledge, Skills and Abilities**
+ Strong knowledge of clinical documentation improvement principles, inpatient coding guidelines, and quality metrics.
+ Excellent analytical and problem-solving skills to identify opportunities for documentation improvement.
+ Proficiency in CDI and medical record software systems (e.g., 3M 360 Encompass, Iodine Interact).
+ Effective communication and interpersonal skills to collaborate with physicians and interdisciplinary teams.
+ Ability to develop and deliver educational programs tailored to clinical and administrative audiences.
+ Strong organizational skills and attention to detail to manage multiple priorities and deadlines.
+ Commitment to maintaining compliance with regulatory standards and corporate policies.
**Licenses and Certifications**
+ RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
+ CCS-Certified Coding Specialist or ICD-10 certification or trainer designation required or
+ Certified Clinical Documentation Specialist (CCDS) required
+ RHIT - Registered Health Information Technician preferred or
+ RHIA - Registered Health Information Administrator preferred
+ CDIP - Clinical Documentation Improvement Professional preferred or
+ Certified Coder-AHIMA or AAPC preferred
Equal Employment Opportunity
This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to to obtain the main telephone number of the facility and ask for Human Resources.
Clinical Documentation Manager
Posted 1 day ago
Job Viewed
Job Description
Job Description - Clinical Documentation Manager (25020940) All the benefits and perks you need for you and your family: Benefits from Day One Paid Days Off from Day One Mental Health Resources and Support Our promise to you: Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by extending the healing ministry of Christ. You will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better. Schedule: Full Time Shift: Days The community you’ll be caring for: AdventHealth Orlando Located on a lush tropical campus, our flagship hospital, 1,368-bed AdventHealth Orlando Serves as the major tertiary facility for much of the Southeast, the Caribbean, and South America Houses one of the largest Emergency Departments and cardiac catheterization labs in the country Provides service to more than 32,000 inpatients and 125,000 outpatients annually The role you’ll contribute: The Clinical Documentation Integrity Manager is a Registered Nurse and/or a Registered Health Information Administrator with a high level of clinical proficiency. This role oversees the Clinical Documentation team, including registered nurses and clinical documentation specialists, reviewing complex patients across different ages and disease states. Must demonstrate leadership and management skills to promote effective documentation review, support patient care levels, and develop improvement plans. Experience in process management, system implementations, and project management is essential. The value you’ll bring to the team: Maintains knowledge of all federal, state, and local documentation guidelines; communicates updates to CDI staff; extensive knowledge of ICD-10 and coding guidelines. Develops and delivers ongoing training for CDI staff, including new hire training, preceptor programs, and refresher courses. Responsible for hiring, performance evaluations, employee counseling, coaching, and termination procedures in compliance with policies. Provides orientation and ensures departmental compliance. Fosters employee engagement and high performance through recognition and learning opportunities. Handles stress appropriately and interacts effectively with team members. Qualifications: 4+ years of Clinical Documentation Integrity experience Nursing Degree (RN, BS, BSN, or higher) or Foreign Medical Graduate At least 1 year of acute clinical experience Proficiency in Microsoft Office (Excel, PowerPoint, Word) Valid State of Florida or multi-state RN license Active State of Florida Nurse Practitioner or Physician Assistant license (if applicable) #J-18808-Ljbffr
Clinical Documentation Manager
Posted 1 day ago
Job Viewed
Job Description
Join to apply for the Clinical Documentation Manager role at Pinnacle Treatment Centers, Inc.
1 day ago Be among the first 25 applicants
Join to apply for the Clinical Documentation Manager role at Pinnacle Treatment Centers, Inc.
Get AI-powered advice on this job and more exclusive features.
We offer competitive salaries, full benefits package, Paid Time Off, and opportunities for professional growth.
Pinnacle Treatment Centers is a growing leader in addiction treatment services. We provide care across the nation touching the lives of more than 35,000 patients daily.
Our mission is to remove all barriers to recovery and transform individuals, families, and communities with treatment that works.
Our employees believe we are creating a better world where lives and communities are made whole again through comprehensive treatment.
As the Clinical Documentation Manager, you are responsible for ensuring the clinical team meets or exceeds the standards for documentation excellence through daily clinical documentation review, support, and training. This role focuses on improving the quality of patient care by working closely with the clinical team and site leadership to ensure that clinical services are delivered efficiently, effectively, and in alignment with the organization's strategic goals.
Benefits:
- 18 days PTO (Paid Time Off)
- 401k with company match
- Company sponsored ongoing training and certification opportunities.
- Full comprehensive benefits package including medical, dental, vision, short term disability, long term disability and accident insurance.
- Substance Use Disorder Treatment and Recovery Loan Repayment Program (STAR LRP)
- Discounted tuition and scholarships through Capella University.
- Masters degree in Social Work, Psychology, Addiction Counseling, or other related field
- Independent Clinical License to practice in the field associated with the master's or higher degree
- IN (Indiana) Specific Requirements:
- LCSW
- LMHC
- LCAC (required to provide supervision)
- LMFT
- Experience treating individuals with substance use disorder preferred
- Counseling and documentation of treatment experience following payer guidelines strongly preferred
- Clinical chart audit experience strongly preferred
- Experience developing and facilitating training for staff strongly preferred
- Monitor all clinical records to ensure clinical quality, timeliness, and thoroughness/ accuracy of all clinical documentation daily.
- Ensure adherence to the clinical program requirements, including clinical documentation that adheres to local/state/federal laws and payor standards.
- Resolve any non-adherence of clinical documentation either by training and coaching the counselor who authored the document for same-day revision or by annotating the document oneself if the counselor is unable to resolve the documentation that does not meet requirements.
- Attend clinical team meetings and other assigned meetings.
- Complete all assigned training courses on schedule.
- Provides teaching and training to support clinical excellence.
- Ensures forms in the Electronic Health Record (EHR) meet applicable standards.
- Collaborates with the Information Technology (IT) team on EHR form development.
- Supports accreditation process, scheduling, and corrective action (when applicable) for the DR&A division.
- Oversees outcomes, processes, and ensures collection and integrity of data across the DR&A division while maintaining confidentiality of patient records/data.
- Develops training material and calendar to support continuous clinical excellence and ensures relevance of training material pertaining to performance outcomes yielded by
- Develops, implements, and maintains quality improvement standards, systems, policies, and procedures as applicable.
- Acts as a resource to teammates to help solve problems related to quality of services.
- Other duties as assigned.
Education
Required
- Masters or better in Psychology or related field
Required
- LCAC
- LMHC
- LCSW
- LMFT
Preferred
- Functional Expert: Considered a thought leader on a subject
- Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well
- Dedicated: Devoted to a task or purpose with loyalty or integrity
Preferred
- Entrepreneurial Spirit: Inspired to perform well by an ability to drive new ventures within the business
- Goal Completion: Inspired to perform well by the completion of tasks
- Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
Pinnacle Treatment Centers is an equal employment opportunity employer and makes employment decisions based on merit and other legitimate business considerations. We want to have the best available persons in every job. Company policy prohibits unlawful discrimination based on race, traits historically associated with race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), parental leave, national origin, gender, gender identity, gender expression, age, ancestry, physical or mental disability, military and veteran status, marital status, sexual orientation, genetic characteristics or information, political affiliation, non-merit based factors or any other consideration made unlawful by applicable federal, state, or local laws. It also prohibits discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has or is perceived as having any of those characteristics. Seniority level
- Seniority level Mid-Senior level
- Employment type Full-time
- Job function Administrative
- Industries Hospitals and Health Care
Referrals increase your chances of interviewing at Pinnacle Treatment Centers, Inc. by 2x
Sign in to set job alerts for Documentation Manager roles.Were unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-LjbffrClinical Documentation Manager
Posted 1 day ago
Job Viewed
Job Description
Join to apply for the Clinical Documentation Manager role at AdventHealth Central Florida 3 days ago Be among the first 25 applicants Join to apply for the Clinical Documentation Manager role at AdventHealth Central Florida Get AI-powered advice on this job and more exclusive features. All the benefits and perks you need for you and your family: Benefits from Day One Paid Days Off from Day One Career Development Whole Person Wellbeing Resources Mental Health Resources and Support Our promise to you: Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better. Schedule: Full Time Shift : Days Location: 900 WINDERLEY PL, Maitland, 32751 The community you’ll be caring for: AdventHealth Orlando Located on a lush tropical campus, our flagship hospital, 1,368-bed AdventHealth Orlando Serves as the major tertiary facility for much of the Southeast, the Caribbean and South America AdventHealth Orlando houses one of the largest Emergency Departments and largest cardiac catheterization labs in the country We are already one of the busiest hospitals in the nation, providing service excellence to more than 32,000 inpatients and 125,000 outpatients each year The Role You’ll Contribute The Clinical Documentation Integrity Manager is a Registered Nurse and/or a Registered Health Information Administrator with a high level of clinical proficiency necessary for the oversight of the Clinical Documentation team which is comprised of registered nurses and clinical documentation specialists. This role will oversee the review processes of complex patients that vary in age and have different developments in the acute and chronic disease states. Must have proven leadership and management skills that will promote effective and efficient review of physician documentation that supports the patient's level of care and develop action plans for improvement. Must have knowledge and job experience in management of processes, system implementations, and project management. The value you’ll bring to the team: Maintains knowledge of all federal, state, and local documentation guidelines and communicates changes to all CDI staff; extensive knowledge of I10 and coding guidelines. Develops, produces, and delivers training for CDI on an ongoing basis. This includes monthly New Hire CDI training, CDI Preceptor Program, and on an as needed basis for current employees in the CDI Department. Responsible for the hiring process for CDI departments. Completes performance evaluations timely and is involved in employee counseling, coaching and termination per policy. Provides orientation for new employees and ensures compliance with department policy and procedure. Maintains high levels of employee engagement and job performance by providing recognition and opportunities for learning. Ability to appropriately handle stress and interact with others. The expertise and experiences you’ll need to succeed: 4 or more years of Clinical Documentation Integrity Experience Nursing Degree (RN, BS, BSN, or advanced degree) or Foreign Medical Graduate 1 or more years of acute clinical experience Experience with Microsoft Office (Excel, PowerPoint, and Word Current valid State of Florida or multi state license as a Registered Nurse Current active State of Florida license as a Nurse Practitioner, Physician Assistant Seniority level Seniority level Mid-Senior level Employment type Employment type Full-time Job function Job function Administrative Industries Hospitals and Health Care Referrals increase your chances of interviewing at AdventHealth Central Florida by 2x Get notified about new Documentation Manager jobs in Maitland, FL . Records and IT Project Management Specialist - Orlando, FL Records and IT Project Management Specialist Assistant Manager, Operations | Florida Mall Pop-Up | Contract Greater Orlando $60,000.00-$5,000.00 1 week ago Accountant – Commercial Properties and Corporate Director of Clinical Documentation Improvement Orlando, FL $8 ,120.00- 117,173.33 1 month ago Experienced Professional, Project Accounting We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI. #J-18808-Ljbffr
Clinical Documentation Manager
Posted 1 day ago
Job Viewed
Job Description
Join to apply for the Clinical Documentation Manager role at Pinnacle Treatment Centers, Inc.
1 day ago Be among the first 25 applicants
Join to apply for the Clinical Documentation Manager role at Pinnacle Treatment Centers, Inc.
We offer competitive salaries, full benefits package, Paid Time Off, and opportunities for professional growth.
Pinnacle Treatment Centers is a growing leader in addiction treatment services. We provide care across the nation touching the lives of more than 35,000 patients daily.
Our mission is to remove all barriers to recovery and transform individuals, families, and communities with treatment that works.
Our employees believe we are creating a better world where lives and communities are made whole again through comprehensive treatment.
As the Clinical Documentation Manager, you are responsible for ensuring the clinical team meets or exceeds the standards for documentation excellence through daily clinical documentation review, support, and training. This role focuses on improving the quality of patient care by working closely with the clinical team and site leadership to ensure that clinical services are delivered efficiently, effectively, and in alignment with the organization's strategic goals.
Benefits:
- 18 days PTO (Paid Time Off)
- 401k with company match
- Company sponsored ongoing training and certification opportunities.
- Full comprehensive benefits package including medical, dental, vision, short term disability, long term disability and accident insurance.
- Substance Use Disorder Treatment and Recovery Loan Repayment Program (STAR LRP)
- Discounted tuition and scholarships through Capella University.
- Masters degree in Social Work, Psychology, Addiction Counseling, or other related field
- Independent Clinical License to practice in the field associated with the master's or higher degree
- IN (Indiana) Specific Requirements:
- LCSW
- LMHC
- LCAC (required to provide supervision)
- LMFT
- Experience treating individuals with substance use disorder preferred
- Counseling and documentation of treatment experience following payer guidelines strongly preferred
- Clinical chart audit experience strongly preferred
- Experience developing and facilitating training for staff strongly preferred
- Monitor all clinical records to ensure clinical quality, timeliness, and thoroughness/ accuracy of all clinical documentation daily.
- Ensure adherence to the clinical program requirements, including clinical documentation that adheres to local/state/federal laws and payor standards.
- Resolve any non-adherence of clinical documentation either by training and coaching the counselor who authored the document for same-day revision or by annotating the document oneself if the counselor is unable to resolve the documentation that does not meet requirements.
- Attend clinical team meetings and other assigned meetings.
- Complete all assigned training courses on schedule.
- Provides teaching and training to support clinical excellence.
- Ensures forms in the Electronic Health Record (EHR) meet applicable standards.
- Collaborates with the Information Technology (IT) team on EHR form development.
- Supports accreditation process, scheduling, and corrective action (when applicable) for the DR&A division.
- Oversees outcomes, processes, and ensures collection and integrity of data across the DR&A division while maintaining confidentiality of patient records/data.
- Develops training material and calendar to support continuous clinical excellence and ensures relevance of training material pertaining to performance outcomes yielded by
- Develops, implements, and maintains quality improvement standards, systems, policies, and procedures as applicable.
- Acts as a resource to teammates to help solve problems related to quality of services.
- Other duties as assigned.
Education
Required
- Masters or better in Psychology or related field
Required
- LCAC
- LMHC
- LCSW
- LMFT
Preferred
- Functional Expert: Considered a thought leader on a subject
- Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well
- Dedicated: Devoted to a task or purpose with loyalty or integrity
Preferred
- Entrepreneurial Spirit: Inspired to perform well by an ability to drive new ventures within the business
- Goal Completion: Inspired to perform well by the completion of tasks
- Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.
Pinnacle Treatment Centers is an equal employment opportunity employer and makes employment decisions based on merit and other legitimate business considerations. We want to have the best available persons in every job. Company policy prohibits unlawful discrimination based on race, traits historically associated with race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), parental leave, national origin, gender, gender identity, gender expression, age, ancestry, physical or mental disability, military and veteran status, marital status, sexual orientation, genetic characteristics or information, political affiliation, non-merit based factors or any other consideration made unlawful by applicable federal, state, or local laws. It also prohibits discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has or is perceived as having any of those characteristics. Seniority level
- Seniority level Mid-Senior level
- Employment type Full-time
- Job function Administrative
- Industries Hospitals and Health Care
Referrals increase your chances of interviewing at Pinnacle Treatment Centers, Inc. by 2x
Get notified about new Documentation Manager jobs in Martinsville, IN .
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#J-18808-LjbffrClinical Documentation Specialist
Posted 1 day ago
Job Viewed
Job Description
CommonSpirit Health Mountain Region is committed to building healthier communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen-both inside our hospitals and out in the community. With locations throughout Colorado, Utah, and Kansas, we deliver the same high standard of care to our employees as we do to our patients. Our 20 hospitals, emergency and urgent care centers, home care and hospice, Flight for Life Colorado TM , telehealth and over 240 physician practices and clinics offer endless opportunities! Here, you can grow your career and impact the people in the communities you serve.
CommonSpirit Health is one of the nation's largest nonprofit, faith-based health systems, with a team of over 150,000 employees and 25,000 physicians and advanced practice clinicians. CommonSpirit operates more than 2,200 care sites and 140 hospitals, serving some of the most diverse communities across the nation, letting humankindness lead the way.
Overview:
As a Clinical Documentation Integrity (CDI) Specialist, you will work under indirect supervision, facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. In this role you will be you will:
+ Educate members of the patient care team regarding documentation guidelines and regulatory requirements, including attending physicians, allied health practitioners, nursing, and case management.
+ Support timely, accurate, and complete documentation of clinical information used for measuring and reporting hospital and physician-based outcomes
+ Work independently majority of the time with a high degree of autonomy.
Qualifications:
In addition to bringing humankindness to the workplace each day, qualified Clinical Documentation candidates will need the following:
Education Requirements
+ Nursing Diploma or Associates Degree Required
+ BSN preferred
License/Certification Requirements
+ Current RN license in state of employment or valid RN license from compact state, required
+ CCDS, preferred
+ CDIP, preferred
Experience Requirements
+ Three years of nursing experience in the inpatient hospital setting (critical care and/or strong med/surg experience preferred) or two years of nursing experience in the inpatient hospital setting and one year of CDI experience
+ Must demonstrate Clinical competency through successfully passing Clinical Competency exam through Nuance
+ Must demonstrate CDI software competency through passing Clintegrity exam within six months of starting role
+ Proficiency with MS Office software
+ Proficient in use of Electronic Health Record
+ Experience in health information management or hospital quality program preferred
+ Self-motivated with excellent interpersonal, critical thinking, analytical, organizational, and writing skills
Physical Requirements
+ Sedentary work -(prolonged periods of sitting and exert up to 10lbs force occasionally)
Your Connected Community:
At CommonSpirit Mountain Region, we believe in the healing power of humanity and serving the common good through our dedicated work and shared mission to celebrate humankindness.
Located in Lakewood, Colorado, St. Anthony Hospital is a Level I Trauma Center where we provide a full range of medical specialties and health care services to Denver and the
surrounding region through our state-of-the-art medical campus and home base for Flight For Life® Colorado. With four trauma rooms including the T-10 room, a dedicated field-to-surgery suite ready 24/7 for trauma surgeons and specially trained teams, our staff can provide life-saving care to the most severely ill and injured patients. In 2023, we received our exciting Magnet® designation! We are so proud of our staff for this achievement, which is awarded to only 10 percent of hospitals around the world.
Numerous other awards, certifications, and accreditations have been granted to us from the American Heart Association; Chest Pain Center (CPC); American College of Cardiology; The Joint Commission's National Quality Approval; the Emergency Nurses Association Lantern Award; NAPBC Accreditation; American College of Radiology and many others. At St. Anthony Hospital. we combine a heritage of expert care with the latest in technology and innovation. If you're looking to be part of a fast-paced environment where you can practice to the top of your profession in trauma, cardiology, stroke, neurosciences, breast imaging, cancer/oncology care, surgery and more, we invite you to apply.
Our Total Reward Offerings:
Be sure to consider our generous benefits as part of your overall compensation! Designed with your well-being in mind, our benefits include:
+ Medical
+ Dental
+ Vision
+ 401K with generous match
+ Daycare FSA that can include a company contribution
+ Tuition Reimbursement
+ Student Loan Forgiveness and more!
View more on our benefits HERE ( .
Pay Range:
$3 .59 - 53.73 / hour
Shift: Days
We are an equal opportunity employer.
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Clinical Documentation Specialist
Posted 1 day ago
Job Viewed
Job Description
Full time
**Shift:**
Day Shift
**Description:**
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 Dubuque Medical Center is a 25-bed critical access hospital, which provides a vital lifesaving link to rural communities in Clayton County and surrounding areas through ambulance and emergency services. MercyOne is committed to providing quality, personalized and safe health care close to home.
The emergency department is staffed 24 hours a day, seven days a week with board certified physicians and advanced level practitioners who are well-trained to treat emergency needs. MercyOne Dubuque Medical Center is certified as a Level IV Trauma Center by the Iowa Department of Public Health.
Want to learn more about MercyOne Dubuque? Click here: Find a Location Dubuque, Iowa (IA), MercyOne Dubuque ( the MercyOne Family! We are looking to hire a Clinical Documentation Specialist
As a Clinical Documentation Specialist at MercyOne, you will utilize advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.
Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.
**Schedule:**
+ Full time 40 hours a week
+ Days
+ Remote
**General Requirements:**
+ Knows, understands, incorporates, and demonstrates the Trinity Health/ Mercy One Mission, Vision, and Values in behaviors, practices, standards, policies, procedures 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 principal 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 judgement 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 to ensure adherence in a manner that reflects honest, ethical and professional behavior.
**Education:**
+ Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) or an Advanced degree in nursing (NP/APN) or Physician Assistant. In the absence of a college degree, must have 3 or more years' experience as an inpatient coder or clinical documentation specialist.
+ Preferred certification or licensure includes:
+ Current Registered Nurse License,
+ Registered Health Information Administrator (RHIA),
+ Registered Health Information Technician (RHIT),
+ Certified Coding Specialist (CCS),
+ Certified Clinical Documentation Specialist (CCDS)
+ Certified Documentation Improvement Professional (CDIP).
+ Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), or as an inpatient coder preferred.
+ Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team.
+ Demonstrated ability to use a standard desktop and Windows based computer system, including a basic understanding of email, internet and computer navigation. Ability to use other software as required to perform the essential functions on the job. Experience with databases, spreadsheet software and presentation software preferred.
+ Data entry skills and typing skills at minimum 30 wpm.
+ Must be comfortable operating independently and in a collaborative 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!
Visit MercyOne Careers ( to learn more about the benefits, culture, and career development opportunities available to you at MercyOne Health System circle of care.
**Our Commitment**
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.
EOE including disability/veteran
Clinical Documentation Specialist
Posted 1 day ago
Job Viewed
Job Description
Full time
**Shift:**
Day Shift
**Description:**
Summary
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 Dubuque Medical Center is a 25-bed critical access hospital, which provides a vital lifesaving link to rural communities in Clayton County and surrounding areas through ambulance and emergency services. MercyOne is committed to providing quality, personalized and safe health care close to home.
The emergency department is staffed 24 hours a day, seven days a week with board certified physicians and advanced level practitioners who are well-trained to treat emergency needs. MercyOne Dubuque Medical Center is certified as a Level IV Trauma Center by the Iowa Department of Public Health.
Posting
Want to learn more about MercyOne Dubuque? Click here: Find a Location Dubuque, Iowa (IA), MercyOne Dubuque ( the MercyOne Family! We are looking to hire a Clinical Documentation Specialist
As a Clinical Documentation Specialist at MercyOne, you will utilize advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant. Facilitates the overall quality, completeness, accuracy and integrity of medical record documentation through extensive record review.
Through extensive interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.
**Schedule:**
+ Full time 40 hours a week
+ Days
+ Remote
**General Requirements:**
+ Knows, understands, incorporates, and demonstrates the Trinity Health/ Mercy One Mission, Vision, and Values in behaviors, practices, standards, policies, procedures 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 principal 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 judgement 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 to ensure adherence in a manner that reflects honest, ethical and professional behavior.
**Education:**
+ Must possess an Associate/Diploma Degree in Nursing, or Health Information Technology (HIT) or an Advanced degree in nursing (NP/APN) or Physician Assistant. In the absence of a college degree, must have 3 or more years' experience as an inpatient coder or clinical documentation specialist.
+ Preferred certification or licensure includes:
+ Current Registered Nurse License,
+ Registered Health Information Administrator (RHIA),
+ Registered Health Information Technician (RHIT),
+ Certified Coding Specialist (CCS),
+ Certified Clinical Documentation Specialist (CCDS)
+ Certified Documentation Improvement Professional (CDIP).
+ Experience in Critical Care, Medical or Surgical Inpatient Care Nursing, as an RN, physician assistant (PA), nurse practitioner/advanced practice nurse (NP/APN), or as an inpatient coder preferred.
+ Excellent communication (verbal and written), interpersonal, collaboration and relationship-building skills. Strong critical thinking skills and ability to integrate knowledge. Prioritization and organizational skills required. Effective presentation/facilitation skills to accomplish educational goals for all members of the healthcare team.
+ Demonstrated ability to use a standard desktop and Windows based computer system, including a basic understanding of email, internet and computer navigation. Ability to use other software as required to perform the essential functions on the job. Experience with databases, spreadsheet software and presentation software preferred.
+ Data entry skills and typing skills at minimum 30 wpm.
+ Must be comfortable operating independently and in a collaborative 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!
Visit MercyOne Careers ( to learn more about the benefits, culture, and career development opportunities available to you at MercyOne Health System circle of care.
**Our Commitment**
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.
Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.
EOE including disability/veteran
Clinical Documentation Specialist
Posted 1 day ago
Job Viewed
Job Description
**PEOPLE ESSENTIAL FUNCTIONS**
+ Improves the overall quality, completeness and accuracy of clinical documentation by performing open record reviews using clinical documentation guidelines. Supports the accuracy and completeness of clinical information used for measuring and reporting physician and medical outcomes.
**SERVICE ESSENTIAL FUNCTIONS**
+ Seeks additional information regarding clinical condition from appropriate clinical personnel and follows up as necessary. Tracks responses and trends completion of DRG/Documentation worksheets as pertinent to scope of department.
+ Conducts follow-up reviews of clinical documentation to ensure points of clarification have been recorded in the patient's chart.
**QUALITY/SAFETY ESSENTIAL FUNCTIONS**
+ Demonstrates knowledge of DRG payor issues, optimization strategies, clinical documentation requirements and referral policies and procedures. Requests clarification and/or correction from physicians for unclear diagnoses, complications, procedures, and clinical information. Helps identify appropriate ICD10 codes for diagnoses or procedures related to projects or studies being conducted as needed.
**FINANCE ESSENTIAL FUNCTIONS**
+ Promotes clarification to clinical documentation to ensure that appropriate reimbursement is received for the level of service rendered to all patients. Identifies diagnoses and procedures performed and comorbidities and complications. Impacts discharges by updating the DRG worksheet to reflect any changes in status, procedures/treatments, conferring with physician to finalize diagnosis as necessary.
**GROWTH/INNOVATION ESSENTIAL FUNCTIONS**
+ Educates all internal customers on clinical documentation opportunities, coding, and reimbursement issues, as well as performance improvement methodologies
This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.
**EDUCATION**
+ Associate's or bachelor's degree in nursing; OR
+ Medical School graduate where Western Medicine is practiced
**WORK EXPERIENCE**
+ For RN - At least five years of recent clinical experience caring for adults in an acute care hospital setting is required; coding and utilization review experience preferred
+ For Medical School graduate - One year of clinical experience preferred
**LICENSES AND CERTIFICATIONS - REQUIRED**
+ RN - Registered Nurse - Texas State Licensure and/or Compact State Licensure within 60 days **OR**
+ RN-Temp - Registered Nurse - Temporary State Licensure within 60 days
+ CCDS - Clinical Documentation Specialists (ASDIS) -- For Medical School graduate **OR**
+ CDIP - Certified Documentation Integrity Practitioner (AHIMA) -- For Medical School graduate **OR**
+ CCS - Certified Coding Specialist (AHIMA) -- For Medical School graduate
**KNOWLEDGE, SKILLS, AND ABILITIES**
+ Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
+ Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
+ Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
+ Demonstrates knowledge of DRG payor issues, appropriate DRG assignment alternatives, clinical documentation requirements, and referral policies and procedures
+ Demonstrates accountability and professional development
+ Requires excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication
+ Regular significant contacts with other personnel throughout the institution (including but not limited to - physicians and their staff, mid-level providers, mid-level staff, coders, Case Managers). Contacts may be in person, by telephone, or through correspondence. Requires assertiveness while being even tempered, with a pleasing personality and the ability to communicate easily with others.
**SUPPLEMENTAL REQUIREMENTS**
**WORK ATTIRE**
+ Uniform No
+ Scrubs No
+ Business professional Yes
+ Other (department approved) No
**ON-CALL***
_*Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below._
+ On Call* No
**TRAVEL***
_**Travel specifications may vary by department**_
+ May require travel within the Houston Metropolitan area No
+ May require travel outside Houston Metropolitan area No
**Company Profile:**
Houston Methodist is one of the nation's leading health systems and academic medical centers. Houston Methodist consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the heart of the Texas Medical Center, and seven community hospitals throughout the greater Houston area. Houston Methodist also includes an academic institute, a comprehensive residency program, a global business division, numerous physician practices and several free-standing emergency rooms and outpatient facilities. Overall, Houston Methodist employs more than 27,000 employees and is supported by a wide variety of business functions that operate at the system level to help enable clinical departments to provide high quality patient care.
Houston Methodist is an Equal Opportunity Employer.