RN Full Time- Health Information Management (HIM)

JOB DESCRIPTION

Employment Type : Full time

Full time

Shift : Description :

Description : Employment Type :

Employment Type : Full Time

Full Time

Shift : Position Purpose :

Position Purpose :

Under limited supervision, concurrently identifies clinical opportunities for compliant documentation to support severity of illness, risk of mortality, level of services provided, quality outcomes and timely completion of the health record documentation.

What you will Do :

• Assesses the medical record to identify possible clinical documentation opportunities which establish medical necessity and appropriate level of care.
• Facilitates accurate clinical documentation that supports severity of illness, risk of mortality, level of services provided, quality outcomes and timely completion of the health record documentation.
• Reviews appropriate CDMP Quick Reference Guides and discusses issues with physicians to help document findings that support medical necessity and appropriate level of care.

Interacts in written form and verbally, with physicians, nursing, ancillary care providers, and coders to obtain compliant documentation consistent with care provided.

• Follows identified charts throughout the hospital stay for continued Clinical Documentation Management Program needs.
• Creates, reviews, and / or revises CDMP Quick Reference Guides, educational handouts, and other program materials as identified.
• Develops and implements continuing CDMP educational programs for physicians, nursing, and ancillary care providers. Maintains collaborative relationship with CDMP physician champions through educational handouts and other program materials as identified.
• Enhances teamwork by utilizing effective communication and delegation principles and techniques.
• Enters data timely and appropriately for measuring documentation outcomes.
• Provides support to physicians and interdisciplinary team members by calculating and documenting concurrent / working DRG in the electronic health record.
• Provides clinical information in preparation for monthly quality monitoring as requested. Provides education, as necessary, to ensure performance improvement.

Minimum Qualifications :

• Is a registered nurse maintaining current licensure defined by Interstate Compact. .
• Certified Clinical Documentation Specialist (CCDS) preferred. Current knowledge of DRG's and Coding practices preferred.
• Broad clinical knowledge with a minimum of three to five years of experience in acute medical / surgical care setting required.
• Excellent interpersonal, written and verbal communication skills.
• Good problem solving skills.
• Maintains a high level of professionalism, which positively promotes the image of Mercy Medical Center.

Position Highlights and Benefits

• The tri-state region, referred to as Western Iowa or Siouxland, is highlighted by safe and friendly communities, excellent schools and a mix of peaceful rural areas and vibrant city atmosphere where Iowa, Nebraska and South Dakota meet at the Missouri River.
• Situated in the heart of downtown Sioux City, MercyOne Siouxland Medical Center is also well positioned for urban living in any of the newly renovated apartments, downtown lofts, or townhome living options.

The downtown also features a historic district with excellent restaurants and social spots, and you'll just be steps away from the beautifully renovated Warrior Hotel for dinner and the gorgeous Orpheum Theatre for entertainment.

We care about your well-being, both physical and mental, which is why our benefit package includes :

• Wellness programs
• Education reimbursement
• Personalized health insurance plans including dental and vision
• Paid time off
• Long- and short-term leave
• Retirement planning
• Life insurance coverage

Ministry / Facility Information

MercyOne Western Iowa serves the needs of individuals in a 33-county area including western Iowa, eastern Nebraska and southeastern South Dakota.

a 238-bed regional facility, is home to the only Level II trauma center in the area one of only four trauma care facilities in the state to receive verification from the American College of Surgeons and MercyOne Air Med, a regional helicopter ambulance service.

Along with owned and managed hospitals in and Hawarden, Iowa, and a partnership with in South Dakota, the region also operates a primary care network, specialty care clinics and home health care, providing an entire continuum of preventative, primary, acute and tertiary health care services to provide personalized, compassionate care for the communities we serve and beyond.

MercyOne Siouxland Medical Center and all its affiliates are proud to be equal opportunity employers. We do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state, or local protected class.