Clinical Document Educator

University of Rochester • City of Rochester, NY

7d • $84,557 - $118,380 • Onsite

About The Position

The University of Rochester is seeking a Clinical Document Educator to join their Utilization Management department. This role involves planning, developing, and implementing comprehensive clinical documentation integrity (CDI) education programs for clinical documentation specialists and providers. The educator will serve as a clinical resource, review patient charts to ensure accurate documentation reflecting severity of illness and intensity of service, and collaborate with various departments to improve documentation practices and quality metrics. The position is full-time, based at 601 Elmwood Ave, Rochester, New York, 14642, and operates on a day shift.

Requirements

• Bachelor's degree in Nursing (BSN), 5 years of acute clinical experience and 4 years of CDI experience required OR Bachelor's degree or Master's degree in a relevant clinical discipline: Prepared Physician Assistant (PA) or Nurse Practitioner (NP) or Bachelor of Medicine, Bachelor of Surgery (MBBS) or Doctor of Medicine/Osteopathic Medicine (MD/DO) required.
• Equivalent combination of education and experience.
• Strong knowledge of medical coding systems, particularly ICD-10-CM/PCS and CPT, including an understanding of coding guidelines, DRG (Diagnosis-Related Group) assignment, and the impact of documentation on reimbursement and quality metrics required.
• Current RN License in NYS upon hire required, or NP - Nurse Practitioner – Licensed Current NP License in NYS upon hire required, or PA - Physician Assistant Current PA License in NYS upon hire required, or MD - Physician - State Licensure Current MD License in NYS upon hire required, or DO - Doctor of Osteopathy Current DO License in NYS upon hire required.
• CDS - Clinical Documentation Specialist upon hire required.
• CDIP - Clinical Documentation Improvement Professional upon hire required.

Nice To Haves

• Hospital databases: EPARC, eRecord, SharePoint, Iodine, 3M preferred.

Responsibilities

• Partners with departmental leadership to plan, develop, and implement comprehensive clinical documentation integrity (CDI) education programs for clinical documentation specialists and providers across URMC.
• Provides orientation oversight for new hires.
• Assists with second-level mortality reviews as needed.
• Provides subject matter expertise in CDI best practices and has a comprehensive understanding of quality metrics and regulatory guidelines.
• Works in collaboration with CDI management, Quality and providers to support the mission, vision, and goals of the CDI Program.
• Serves as a clinical resource for staff and ancillary departments.
• Reviews patient charts to ensure the documentation accurately reflects the severity of illness and intensity of service with consideration of CMS guidelines.
• Assists with new policy/guidelines and/or updates annually.
• Develops and maintains tracking tools for departmental and interdepartmental training.
• Works collaboratively with leadership to identify areas for clinical documentation improvement and directs training and education to enhance documentation practices.
• Develops an annual education plan for staff and providers in collaboration with leadership and analysts.
• Assists with the development of an orientation program for new hires.
• Works collaboratively with Service Lines and Service Line Champions to educate providers on best practice documentation and quality-related topics.
• Plans, develops, and implements education programs to improve provider clinical documentation and to ensure an accurate clinical picture of the patient, including severity of illness, risk, and resource utilization.
• Works with all customers to determine the best strategies for disseminating information.
• Serves as a resource to CDI, Coding, and providers.
• Provides clinical care teams with ongoing education and training on current trends in clinical documentation.
• Identifies areas for improvement.
• Designs, coordinates, and delivers educational programs focused on clinical documentation improvement for CDI Specialists and providers.
• Delivers individual and large-group educational sessions to enhance staff knowledge, regulatory compliance, and adoption of industry best practices.
• Maintains current expertise in clinical documentation, compliance standards, and emerging trends through participation in workshops, conferences, in-services, and active membership in Association of Clinical Documentation Integrity Specialists (ACDIS), applying this knowledge to strengthen departmental performance and educational initiatives.
• Ensures compliance with all mandatory and departmental education requirements, RN or other relevant clinical licensure, and Clinical Documentation Specialist (CDS) certification requirements.
• Consistently models ICARE values in interactions with internal and external customers.
• Maintains awareness of hospital and departmental improvement goals and participates in data collection.
• Collaborates with the Quality Department to review and prioritize CDI opportunities to improve quality metrics and to trend the quality metrics most impacted by documentation (PSI, CMS, CMI, and Vizient data).
• Participates in departmental meetings.
• Works closely with leadership and staff to improve documentation templates in support of clinical treatment protocols.
• Collaborates with leadership and other clinicians to facilitate the ongoing relevance of department-specific orientation content, educational materials, documentation tip sheets, and training programs/resources.
• Assists with the preparation of data and reports to evaluate the effectiveness and overall impact of the clinical documentation improvement program for presentation in departmental meetings and appropriate oversight committees.
• Other duties as assigned.

Benefits

• The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level