Clinical Document Specialist (1.0 D)

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

• Certified Clinical Documentation Specialist (CCDS) - Association of Clinical Documentation Integrity Specialists (ACDIS) - Preferred

EQUAL OPPORTUNITY EMPLOYER

It is the policy of Franciscan Alliance to provide equal employment to its employees and qualified applicants for employment as otherwise required by an applicable local, state or Federal law.

Franciscan Alliance reserves a Right of Conscience objection in the event local, state or Federal ordinances that violate its values and the free exercise of its religious rights.

Franciscan Alliance is committed to equal employment opportunity.

Franciscan provides eligible employees with comprehensive benefit offerings. Find an overview on the benefit section of our career site, jobs.franciscanhealth.org.