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RN Clinical Documentation Spec in Cincinnati, OH at Mercy Health

Date Posted: 6/8/2018

Job Snapshot

Job Description

Job Summary


A summary of the specific skills, knowledge and behaviors of this position are: Facilities improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains and promotes appropriate clinical documentation through extensive interaction and physicians, nursing staff, other patient caregivers and Health Information Management coding staff to ensure clinical documentation reflects the level of service rendered to patients is complete and accurate. Educates all members of patient care team on documentation guidelines, on an on-going basis.


  • Incorporates the Core Values and Success Factors that support the Mission and Vision of Catholic Health Partners.
  • Facilities appropriate clinical documentation to ensure the level of services and acuity of care are accurately reflected in the medical record. Performs admission reviews for specific patient populations using clinical documentation guidelines. Assists in medical screening process by documenting appropriateness of patient admission, working DRG & LOS info on worksheet and computer system as appropriate. Extensively reviews all physician and clinical documentation, lab results, diagnostic information, and treatment plans and captures appropriate information on CDMP worksheet. Utilizes clinical skills to identify documentation opportunities that reflect severity of illness, acuity and resource consumption. Verbally communicates with appropriate physicians(s) to ensure documentation opportunities are clarified. Communicates with ancillary personnel to clarify potential documentation opportunities.
  • Updates DRG worksheet to relfect any changes in patient status, procedures/treatments, and confers with physician to finalize diagnoses. Reviews medical record every 24-48 hours as appropriate. Updates Clinical Documentation Management Program worksheet to reflect any changes in DRG assignment. Communicates with physician to ensure that request for documentation has been noted. Confers with physician to establish appropriate sevverity of illness and ensure documentation of principal diagnosis, comorbid conditions, complications and procedures.
  • Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in patient's chart. As appropriate, documents, analyzes data and reports instances of inappropriate patient care, discharge delays, etec. to Manager of Health Records Services. Follows established CDMP process for follow-up reviews and physician communication.
  • Reviews clinical issues with coding staff to assign working DRG usng software. Collaborates with coding staff as needed to determine appropriate DRG and required documentation. Utilizes coding staff knowledge of Coding Clinics that impact CDMP. Provides clinical expertise and references to the coding staff. Follows established guidelines for reconciling final coded DRG with the CDMP DRG assigned at the time of discharge.
  • Stays current with the conducts on-going clinical documentation management program education for new staff, including new clinical documentation specialists, physicians and nursing and allied health professionals. Tracks and trends program compliance. Attends and participates in weekly educational conferences. Participates in concurrent performance improvement activities an on-going MR review activities. Reviews CDMP tracking data in conjunction with established benchmarks. Provides overview of CDMP to new staff, allied health professionals and physicians.
  • Maintains positive open communications with physicians, interdisciplinary care team members, coding staff, Regional Manager of Coding, Quality and Compliance.


  • Must be a Registered Nurse in the State of Ohio
  • 5 years experience in MDS LTC preferred


Part-Time; 20 hours/week

Days: 8:00am - 4:30pm

Equal Employment Opportunity

It is our policy to  abide by all Federal and State laws, as well as, the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a), prohibiting discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibiting discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity, or national origin.