Clinical Documentation Specialist

Job Summary

Location:

Methodist Jennie Edmundson Hospital, 933

E. Pierce St., Council Bluffs, IA

Work Schedule:

Mon – Fri, daytime business hours.

Responsible for concurrent review of clinical documentation for selected admissions to ensure an accurate representation of the clinical condition of the patient through complete and accurate reporting of diagnoses and procedures.

• Perform concurrent review of clinical documentation for selected admissions, ensuring documentation supports and accurately reflects all disease processes being treated.
• Conduct 25–30 reviews daily.
• Assist with development of physician queries to comply with the query process, ensuring correct clinical diagnoses and capture of severity of illness.
• Demonstrate knowledge of appropriate, worded queries that meet regulatory, legal, and ethical standards.
• Initiate assertive professional communication with physicians when documentation is unclear, incomplete, or lacks necessary completeness to assign ICD‑10 codes by completing query forms or face‑to‑face communication.
• Track responses to documentation queries, monitoring compliance and identifying opportunities for physician feedback and education.
• Maintain collaborative relationships with coding staff, staff nurses, care coordinators, utilization review staff and other hospital personnel.
• Provide education and training to physicians, physician office staff, nurses and coders, including one‑on‑one sessions, group presentations and quick sessions during rounds.
• Work with physicians, care coordinators, utilization management, staff nurses and Coding Specialists to ensure the medical record accurately reflects patient acuity for quality reporting and case mix index.

• Education: Graduate of an accredited school of nursing required. Bachelor of Science in Nursing (BSN) preferred. Successful completion of annual mandatory education requirements.
• Experience: Five years clinical experience in medical‑surgical nursing and/or ICU, or case management, or inpatient clinical coding, or healthcare revenue cycle.
• License/Certification: Current valid Registered Nurse (RN) license, valid compact multistate license, or a temporary permit while awaiting licensure required.
• Skills/Knowledge/Abilities: Excellent communication skills; verbal, written and strong teaching skills; critical thinking; knowledge of healthcare delivery system; develops collaborative relationships with physicians; self‑starter able to deal with resistance and complex situations; fosters teamwork and trust; functions as an educator and enabler to physicians, must be objective and logical.

• Weight Demands:
  Light work – up to 20 pounds of force.
• Physical Activity:
  • Not necessary: climbing, crawling, kneeling.
  • Occasionally performed (1–33%): balancing, carrying, crouching, distinguishing colors, grasping, lifting, pulling/pushing, standing, stooping/bending, twisting, walking.
  • Frequently performed (34–66%): keyboarding/typing, reaching, repetitive motions, sitting, speaking/talking.
  • Constantly performed (67–100%): hearing, seeing/visual.

• Not Related:
  Chemical agents (toxic, corrosive, flammable, latex); physical hazards (noise, temperature, lighting, wet floors, outdoors, sharps); equipment/machinery/tools; explosives; electrical shock/static; radiation (alpha, beta, gamma, non‑ionizing); mechanical moving parts/vibrations.
• Rare (1–33%):
  Biological agents (airborne and blood borne viruses) (Jobs with patient contact).

Nebraska Methodist Health System is an affirmative action/equal opportunity employer and does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, sexual orientation, gender identity, or any other classification protected by Federal, state or local law.