Clinical Documentation Specialist

Genesis HealthCare System - Zanesville, OH3.4

Full-timeEstimated: $47,000 - $64,000 a year

In order to fulfill our Mission of providing Compassionate, Quality HealthCare, all employees of Genesis HealthCare System must be committed to living the Genesis Mission and Genesis values of Compassion, Trust, Innovation, and Excellence. All employees must regard themselves as an "owner" of Genesis and keep our patients at the center of everything we do - always.

Position Details:

FT 30-40 BENEFITS. FTE: 1.000000

Genesis Hospital - Maple Campus

Overview of position:
Role expectations for the Clinical Documentation Specialist includes, assessing, organizing, and implementing a clinical documentation system to improve reimbursement and to more accurately describe the patients clinical condition. Clinical Documentation Specialists analyze and trend data results in order to optimize efficiency of operational systems through strategic quality leadership.

Essential Duties:
Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation. Develops and implements action plans to improve physician responses based on identified trends.
Works closely with HIM coding staff to assure documentation of discharge diagnosis and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care. Helps HIM complete retrospective physician queries with unclear documentation, as needed.
Follows guidelines for coding and documentation to ensure physician and hospital compliance. Remains current with coding information to ensure accuracy of codes assigned based on documentation.
Consistently meets established productivity targets for record review. Keeps CDMP database updated and current. Monitors number of cases reviewed, number of cases queried and number of successful queries accepted by each specific physician. Produces reports as requested and produces a monthly summary report.
Develops and implements plans for both formal and informal education of physician, nursing, and other clinical staff.
Collaborates with Case Management staff and acts as a resource for the interdisciplinary team to promote collaboration and coordination of patient care, considering age specific, developmental, cultural and spiritual needs of the patient.
Initiates appropriate referrals of quality issues to QI department and Customer Relations, as identified.
Develops, implements and maintains departmental policies and procedures related to clinical documentation improvements.
Performs other functions as assigned.

Minimum Qualifications:
Other information:
Current licensure as a registered nurse by the State of Ohio.
Minimum five (5) years experience adult inpatient med-surg or critical care.
In depth knowledge and understanding of local, state, and federal rules and requirements related to employment.
Excellent interpersonal, decision-making, analytical facilitation, conflict resolution and investigative skills.
Demonstrated excellence with listening, verbal and written communication skills.
Ability to provide outstanding customer service and maintain a high degree of confidentiality.
Ability to work independently and under pressure in a complex and changing working environment.
Excellent computer skills and knowledge of computer software, including programs such as Word, Excel, PowerPoint, etc.

Patient Centered Care & Behavioral Expectations at Genesis HealthCare System:

1. Living the Genesis Mission, Vision and Values:
  • Performs work in a manner that is quality focused.
  • Treats patients, co-workers, visitors and volunteers with courtesy, compassion, empathy and respect.
  • Results oriented and focused on achievement of objectives.
  • Acknowledges and responds to the diversity of people and the situation.
  • Encourages peers (others) to be owners of change.
  • Always makes the effort to anticipate and exceed customer needs and expectations.
  • Possesses the ability to engage others with patience and understanding.
  • Acts in a manner that creates positive first and lasting impressions.
  • Demonstrates the ability to own issues until they are resolved.
2. Patient Centered Care (patients/families, physicians, co-workers, all other internal/external customers)

  • Introduces self and role…connects with everyone.
  • Communicates effectively (i.e. advising others of actions, pertinent information, time durations, etc.) and asks for feedback.
  • Asks for and anticipates needs and concerns of others.
  • Maintains a positive work environment for staff and a healing environment for patients (i.e. safe, clean, quiet, etc.)
  • Maintains the dignity and privacy of each person; manages confidential/sensitive information appropriately.
  • Responds to requests in an appropriate and timely manner.
  • Exits patient/customer encounters courteously, asking if there are additional needs that can be addressed.
3. Promotes Patient and Employee Safety

  • Demonstrates safe Patient Handling (i.e. transfers, transport, care administration, nutrition, medication, etc.)
  • Demonstrates safe Materials Handling (i.e. appropriate use and disposal of chemicals, infectious wastes, etc.)
  • Demonstrates appropriate knowledge of Infectious Disease precautions and use of proper protective equipment.
  • Demonstrates Slips/Trips and Falls Awareness.
  • Actively contributes to maintaining a safe, clean and quiet environment.
Working Conditions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Working conditions:
This description reflects in general terms the type and level of work performed. It is not intended to be all-inclusive, nor portray the specific duties of any one incumbent.

Thank you for your interest in employment at Genesis. Genesis is committed to being an equal opportunity employer. Selection of applicants for employment is based only on qualifications and the requirements of a specific job.