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  • CDI RN - Clinical Documentation Specialist…

    Trinity Health (Sioux City, IA)



    Apply Now

    Employment Type:

    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 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.

     

    Want to learn more about MercyOne Sioux City? Click here:

     

    Find a Location Sioux City, Iowa (IA), MercyOne Siouxland (https://www.mercyone.org/siouxland/find-a-location/)

     

    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, 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 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 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 in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

    Mi** **n** **imum Qualifications** **:

    + Is a registered nurse maintaining current licensure defined by Interstate Compact. A senior level nursing student of 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.

    + Maintainsa 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 partnership 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!

     

    Visit MercyOne Careers (https://www.mercyone.org/careers/) to learn more about the benefits, culture, and career development opportunities available to you at MercyOne Health System circle of care.

     

    Visit MercyOne on LinkedIn (https://www.linkedin.com/company/saint-alphonsus-health-system/) , Facebook (https://www.facebook.com/SaintAlphonsus/) , Instagram (https://instagram.com/saintalphonsus?utm\_source=ig\_profile\_share&igshid=1ecujfk63xezr) , YouTube (https://www.youtube.com/channel/UCFgYXHlHzYPLDjozyU03WGA) , and Twitter (https://twitter.com/SaintAlsHealth) !

     

    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

     


    Apply Now



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