RN Clinical Documentation Specialist Registered Nurse - Full Time, Days

Attention current TriHealth employees:

Please apply for this position by submitting an online internal application via SuccessFactors. Please be certain to update your SuccessFactors Employee Profile prior to applying to this position.

CLINICAL DOCUMENTATION SPECIALIST

Concurrently review inpatient medical records for accuracy and completeness of documentation on admission and throughout hospitalization. Ensure the accuracy and completeness of clinical information within the chart by analyzing for potential gaps in physician documentation through clarifications to improve documentation on principal diagnosis, co-morbidities, present on admission and quality core measures. Facilitate improvement in clinical documentation through education and extensive interaction with physicians, nursing staff and all other members of the health care team. Systematic development and implementation of educational opportunities for physicians, nursing staff and all other members of the health care team. Collaboration with coding staff in assuring complete and compliant documentation in all inpatient charts at time of discharge. Participates in the interdisciplinary process to ensure that selected clinical quality indicators are met.

MINIMUM REQUIREMENTS

• EDUCATION:
  • Bachelor's Degree in Nursing
  • Registered Nurse in the State of OH
  • BLS/CPR (Basic Life Support for Healthcare Providers)
• EXPERIENCE:
  • 5-7 years of clinical nursing experience in Med/Surg or ICU.
• SPECIALIZED KNOWLEDGE:
  • Basic keyboarding and Microsoft Office.
• DEPARTMENT SPECIFIC QUALIFICATIONS:
  • In order to be successful the clinical documentation specialist must possess the ability to communicate effectively verbally and in written form with medical records staff, residents, physicians and all members of the health care team.
  • They must be organized, critical thinkers, work well independently and possess excellent keyboard skills.
  • Knowledge of CMS guidelines, coding clinics and previous clinical documentation is a plus.

Job keywords:

Certified Operating Room Nurse (CNOR), Charge Nurse, Emergency Department RN (Emergency Department Registered Nurse), Oncology RN (Oncology Registered Nurse), Operating Room Registered Nurse (OR RN), Psychiatric RN (Psychiatric Registered Nurse), Relief Charge Nurse, School Nurse, Staff Nurse, Staff RN (Staff Registered Nurse)

Job Title:  RN Clinical Documentation Specialist Registered Nurse - Full Time, Days

Department Name:  GSH CLINICAL DOCM MGMT

Location:  Good Samaritan Hospital

Hourly/Salaried:  Salaried

Employment Status: Full Time Position

Bi-Weekly Hours:80

Shift: Day Shift

Weekend Commitment:  Yes

Holiday Commitment:  No

On-Call Commitment:  No