Registered Nurse, Clinical Documentation Specialist

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🏈 Ohio – Remote

🏈 Ohio – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥📝 Medical Writer

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Bon Secours Mercy Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 2018

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Bon Secours Mercy Health is a leading health care organization committed to transforming health care delivery and services through strategic innovation and compassionate care. Operating hospitals and clinical sites in the U. S. and Ireland, the organization focuses on extending health care access, improving patient outcomes, and enhancing value through emerging technologies and strategic partnerships. With a commitment to service and stewardship, Bon Secours Mercy Health also prioritizes enhancing the quality of life for underserved communities while advocating for sustainability. The organization’s initiatives include digital innovation, diversified growth through investments and partnerships, and providing high-value care across its core clinical operations.

📋 Description

• Facilitate improvement in the quality, completeness, and accuracy of medical record documentation • Obtain and promote appropriate clinical documentation through extensive interaction with physicians, nursing staff, caregivers, and Health Information Management coding staff • Educate patient care team members on documentation guidelines • Perform admission reviews for specific patient populations using clinical documentation guidelines • Assist in medical screening by documenting admission appropriateness and working DRG and LOS information • Review physician and clinical documentation, laboratory results, diagnostic information, and treatment plans • Identify documentation opportunities reflecting severity of illness, acuity, and resource consumption • Communicate with physicians and ancillary personnel to clarify documentation opportunities • Update DRG and Clinical Documentation Management Program worksheets based on patient status, procedures, treatments, and documentation • Review medical records every 24–48 hours as appropriate • Confer with physicians regarding severity of illness, principal diagnoses, comorbid conditions, complications, and procedures • Conduct follow-up reviews to ensure clarified issues are documented in patient charts • Document, analyze, and report inappropriate patient care and discharge delays as appropriate • Collaborate with coding staff to determine appropriate DRG and required documentation • Provide ongoing clinical documentation management education for new staff, physicians, nursing, and allied health professionals • Track and trend program compliance • Participate in concurrent performance improvement and medical record review activities • Maintain communication with physicians, interdisciplinary care team members, coding staff, and regional management

🎯 Requirements

• Registered Nurse (RN) with 5+ years of experience in Med/Surg, Critical Care, ICU, or ED • Active RN license in Ohio or Kentucky required • Certified Clinical Documentation Specialist (CCDS) preferred • Score of 70% or greater on JA Thomas's Clinical Competency Assessment required • Excellent verbal and written communication skills • Excellent interpersonal skills • Ability to demonstrate excellent physician relations

🏖️ Benefits

• Competitive pay • Incentives • Referral bonuses • 403(b) with employer contributions (when eligible) • Medical coverage • Dental coverage • Vision coverage • Prescription coverage • HAS/FSA options • Life insurance • Mental health resources and discounts • Paid time off • Parental leave • FMLA leave • Short- and long-term disability • Backup care for children and elders • Tuition assistance • Professional development • Continuing education support