Medical writer

• Direct efforts toward the integrity of clinical documentation as a reviewer, educator and consultant
• Facilitate the quality, completeness and accuracy of medical record documentation through extensive record review
• Demonstrate understanding of documentation requirements so severity of illness, risk of mortality, quality indicators and level of services are accurately reflected
• Communicate with and educate physicians and healthcare team members on clinical documentation
• Monitor provider engagement
• Conduct concurrent reviews of selected patient health records for legibility, clarity, completeness, consistency and precision
• Formulate compliant clarifications/queries following Trinity Health's documentation integrity procedures
• Incorporate Trinity Mission, Vision and Values into behaviors, practices, standards, policies, procedures and decisions

Clinical Documentation Specialist

• Utilize clinical and coding expertise to support the integrity of clinical documentation as reviewer, educator and consultant
• Facilitate the quality, completeness and accuracy of medical record documentation through extensive record review
• Demonstrate understanding of documentation needed to accurately reflect severity of illness, risk of mortality, quality indicators and level of services
• Communicate with and educate physicians and healthcare team members on clinical documentation
• Monitor provider engagement
• Conduct concurrent reviews of selected patient health records for legibility, clarity, completeness, consistency and precision
• Formulate compliant clarifications/queries according to Trinity Health documentation integrity procedures
• Incorporate the Trinity Mission, Vision and Values into behaviors, practices, standards, policies, procedures and decisions

Employment Type:
Full timeShift:
Day Shift
Description:
MercyOne Genesis Full-Time Remote Position (80 Hours Biweekly)
AA degree in Nursing or HIT. In absence of a degree, 3 years' experience as an inpatient coder or a clinical documentation specialist requiredEssential Functions:

- Knows, understands, incorporates and demonstrates the Trinity Mission, Vision and Values in behaviors, practices, standards policies procedures and decisions.

- Demonstrates understanding of appropriate clinical documentation to ensure the severity of illness, risk of mortality, quality indicators and level of services provided are accurately reflected in the health record.

- Communicates with and educates physicians and all other member of the healthcare team in clinical documentation and monitors provider engagement.

- 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.

Minimum Qualifications:

- Must possess an Associate/Diploma Degree in Health Information Technology (HIT) or Advanced degree in nursing (NP, APN) or Physician Assistant. In absence of college degree, must have three (3) years' experience as an inpatient code or documentation specialist.

- Preferred Certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP

- Experienced in critical care, medical or surgical inpatient care nursing as an RN, PA, NP, APN or inpatient coder preferred

- Excellent communication, interpersonal, collaboration and relationship building skills. Strong critical thinking skills, and ability integrate knowledge. Prioritization and organizations skills required.

- Demonstrated ability to use standardized desktop and Windows based computer system. Data entry and typing skills at minimum 30 wph.

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.

Clinical Documentation Specialist Remote

Employment Type:
Full timeShift:
Day Shift
Description:
MercyOne Genesis Full-Time Remote Position (80 Hours Biweekly)
AA degree in Nursing or HIT. In absence of degree, 3 years' experience as an inpatient code or clinical documentation specialist

Position Purpose:
Utilizes 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 and accuracy of medical record documentation through extensive record review.Essential Functions:

- Knows, understands, incorporates and demonstrates the Trinity Mission, Vision and Values in behaviors, practices, standards policies procedures and decisions.

- Demonstrates understanding of appropriate clinical documentation to ensure the severity of illness, risk of mortality, quality indicators and level of services provided are accurately reflected in the health record.

- Communicates with and educates physicians and all other member of the healthcare team in clinical documentation and monitors provider engagement.

- 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.

Minimum Qualifications:

- Must possess an Associate/Diploma Degree in Health Information Technology (HIT) or Advanced degree in nursing (NP, APN) or Physician Assistant. In absence of college degree, must have three (3) years' experience as an inpatient code or documentation specialist.

- Preferred Certifications: RN, RHIA, RHIT, CCS, CCDS or CDIP

- Experienced in critical care, medical or surgical inpatient care nursing as an RN, PA, NP, APN or inpatient coder preferred

- Excellent communication, interpersonal, collaboration and relationship building skills. Strong critical thinking skills, and ability integrate knowledge. Prioritization and organizations skills required.

- Demonstrated ability to use standardized desktop and Windows based computer system. Data entry and typing skills at minimum 30 wph.

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.

• Utilize clinical and coding expertise to direct efforts toward the integrity of clinical documentation as reviewer, educator and consultant
• Facilitate the quality, completeness and accuracy of medical record documentation through extensive record review
• Ensure clinical documentation accurately reflects severity of illness, risk of mortality, quality indicators and level of services provided
• Communicate with and educate physicians and healthcare team members on clinical documentation
• Monitor provider engagement
• Conduct concurrent reviews of selected patient health records for legibility, clarity, completeness, consistency and precision
• Formulate compliant clarifications/queries following Trinity Health's documentation integrity procedures
• Demonstrate the Trinity Mission, Vision and Values in behaviors, practices, standards, policies, procedures and decisions

• Demonstrate Trinity Mission, Vision and Values in behaviors, practices, standards, policies, procedures and decisions
• Ensure clinical documentation accurately reflects severity of illness, risk of mortality, quality indicators and level of services provided
• Communicate with and educate physicians and healthcare team members on clinical documentation
• Monitor provider engagement
• Conduct concurrent reviews of selected patient health records for legibility, clarity, completeness, consistency and precision
• Formulate compliant clarifications/queries following Trinity Health's documentation integrity procedures