Senior Clinical Documentation Specialist This position is an advanced CDI role. The Senior Clinical Documentation Specialist coworker is responsible for assisting in the overall integrity of the medical record documentation primarily by conducting reviews of inpatient medical records to identify missing, vague, and/or incomplete components; communicates the need for additional documentation to the appropriate clinical provider and/or coding; ensures the additional documentation is completed in a timely manner; works collaboratively other departments including coding, quality, compliance, the medical staff, utilization review/case management, and any other applicable departments to improve the quality of provider documentation; supports initiatives to improve the quality of documentation by all caregivers. This position provides data reports and educational support for required documentation elements to inpatient healthcare providers. Performs duties and responsibilities in a manner consistent with our mission, values, and Mercy Service Standards.
Position Details: Minimum Required Qualifications
Education: RN, BSN, RHIA, RHIT, CCS, CPC, CIC, CCDS, or CDIP
Experience:
3 years CDI experience and 1 year in nursing, inpatient coding, UM, CM, Quality, or related field Other Skills and Knowledge:
- Demonstrates proficiency of the Clinical Documentation Specialist role
- Detailed data analysis, ability to present complex data or education to providers individually or in front of a group
- Excellent critical thinking skills with the ability to quickly make decisive decisions from limited written and/or oral information, excellent reading comprehension
- Strong clinical knowledge and ability to identify diagnoses based on clinical data
- Extensive knowledge of disease processes and clinical outcomes.
- Experience with computer programs (EXCEL, Word, PowerPoint)
- Advanced knowledge of healthcare regulations, including reimbursement, documentation requirements, and quality measures
- Skilled in record review with ability to interpret clinical data
- Assist in special projects and committees
- Excellent communication skills (written and verbally) and comfortable speaking in groups.
- Ability to plan and organize workflow in order to meet deadlines
- Must have strong computer skills including typing ability.
- Ability to produce reports using multi-formats and software
- Ability to interpret various data reports and present data findings / report to medical staff committees as needed
- Ability to establish cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines and interact with all levels of employees
- Ability to mentor lower-level CDI Specialists
- Ability to work flexible work schedules to accommodate provider rounding schedules and required medical staff presentations
- Ability to work with minimum supervision; organizational and administrative skills; function in a stressful environment; encourage and assist with team building; and the ability to maintain the confidentiality of sensitive information, both patient and employee
Preferred Qualifications
Education: RN, BSN, RHIA, RHIT, CCS, CPC, CIC
Experience: 3-5 years CDI experience
Certification/Registration:
CCDS (Certified Clinical Documentation Specialist) from ACDIS or CDIP (Certified Documentation Improvement Practitioner) from AHIMA preferred Other Skills and Knowledge: Why Mercy? From day one, Mercy offers outstanding benefits - including medical, dental, and vision coverage, paid time off, tuition support, and matched retirement plans for team members working 32+ hours per pay period. Join a caring, collaborative team where your voice matters. At Mercy, you'll help shape the future of healthcare through innovation, technology, and compassion. As we grow, you'll grow with us.
