Clinical Document Specialist (1.0 D)

Work From HomeWork From Home Work From Home, Indiana 46544 The Clinical Document Specialist is responsible for improving the overall quality and completeness of clinical documentation. In this role you will facilitate modifications to clinical documentation through extensive concurrent interaction with physicians and coding staff to ensure that the record accurately reflects the diagnosis treated, procedures performed and the severity of illness of the patient. WHO WE ARE With 11 ministries and access points across Indiana, Franciscan Health is one of the largest Catholic health care systems in the Midwest. Franciscan Health takes pride in hiring coworkers that provide compassionate, comprehensive care for our patients and the communities we serve. WHAT YOU CAN EXPECT Communicate with physicians, regarding missing, unclear or conflicting medical record documentation through the query process to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness. Communicate with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation ensuring they reflect clinical treatment, decisions, and diagnoses for inpatients. Utilize your expertise in understanding of complications, co-morbidities, the severity of illness, the risk of mortality, case mix, secondary diagnosis, and the impact of procedures on the final DRG; and share this knowledge to physicians and other members of the healthcare team. Identify patterns, trends, variances, and opportunities to improve the documentation review and process. QUALIFICATIONS Associate's Degree Nursing or Healthcare related field - Required Bachelor's Degree Nursing or Healthcare related field - Preferred 7 years acute care nursing in lieu of Bachelor's Degree - Required 2 years Recent inpatient, case management, or ED - Required Registered Nurse (RN) - State Licensing Board - Preferred Cert