Clinical Documentation Improvement Specialist-RN

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Department:

FIN | CORE CDI Clinical Doc Team

Department’s Website:

Summary of Job Duties:

The Clinical Documentation Improvement Specialist is responsible for improving overall quality and completeness of clinical documentation to ensure that the information in the medical record accurately reflects the patient’s severity of illness, clinical needs, and utilization of resources. This position is responsible for reviewing death medical records to ensure the severity of illness and risk of mortality has been captured at the highest level. This position works with the providers of care to capture the clinical care in a code format for reimbursement and to ensure UAMS has the correct case mix. Reviews all admission types to the hospital to ensure of severity is captured and then educates the providers of care on admission types.

Qualifications:

Minimum Qualifications:

• Registered Nurse (RN) with current license plus 4 years inpatient clinical experience in Emergency, Critical Care, or Medical/Surgical area with experience in Quality, Case Management, Clinical Audit, or Data Abstraction OR Coding professional with CCS certification and 6 years of inpatient coding experience with documented education in anatomy/physiology and pharmacology.

Preferred Qualifications:

• Current CCDS

Additional Information:

• Applies extensive clinical knowledge to read and analyze health record documentation, identifying all significant diagnoses, treatment, and procedures impacting acuity level and resources consumed throughout the current hospitalization; applies knowledge of disease processes, surgical procedures, UHDDS definitions, and the CMS/NCHS ICD-10 Official Coding Guidelines for Coding and Reporting to assign non-indexed terms to the appropriate class within the ICD-10 coding classification system.
• Reviews all death medical records and works with Vizient calculator to ensure risk of mortality and severity of illness scores are correct. Reviews all admission types to the hospital to ensure severity is captured.
• Interacts directly with physicians, nursing staff, other patient caregivers, coding staff, and other members of the health care team to facilitate clarification of clinical documentation and transfer of knowledge related to accurate documentation, coding, and reimbursement practices; ensures that documentation is clear, concise, and written in diagnostic terms reflecting the highest level of specificity.
• Develops and facilitates education related to clinical documentation improvement, coding guidelines, and regulatory requirements to all members of the healthcare team through one-on-one communication and classroom or large group presentations throughout the year as assigned.
• Performs other duties as assigned.

Salary Information:

Commensurate with education and experience

Required Documents to Apply:

List of three Professional References (name, email, business title), Resume

Proof of Veteran Status

Special Instructions to Applicants:

Please contact“>

Please do not send to listed recruitment contact.

Pre-employment Screening Requirements:

Criminal Background Check

This position is subject to pre-employment screening (criminal background, drug testing, and/or education verification). A criminal conviction or arrest pending adjudication alone shall not disqualify an applicant except as provided by law. Any criminal history will be evaluated in relationship to job responsibilities and business necessity. The information obtained in these reports will be used in a confidential, non-discriminatory manner consistent with state and federal law.

Constant Physical Activity:

Manipulate items with fingers, including keyboarding, Sitting

Frequent Physical Activity:

Feeling, Hearing, Repetitive Motion, Talking

Occasional Physical Activity:

Crouching, Grasping, Kneeling, Lifting, Pulling, Pushing, Reaching, Standing, Stooping, Walking

Benefits Eligible:

Yes