Clinical Document Spec

University of Rochester • City of Rochester, NY

3d

About The Position

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive. Responsibilities: Facilitates clinical documentation improvement through concurrent and retrospective interaction with physicians and members of the healthcare team. This interaction supports the clinical severity of the inpatient admission, quality documentation standards that align with federal and state regulations and assists with maximizing revenue.

Requirements

• Bachelor's degree in Nursing (BSN) and 5 years of inpatient clinical experience, knowledge of complex disease processes required OR Bachelor's, Master's or Doctorate 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) and 5 years inpatient clinical experience, knowledge of complex disease processes required. Or equivalent combination of education and experience.
• Registered Nurse License, current in NYS upon hire required or NP – Nurse Practitioner license, current in NYS upon hire required or PA – Physician Assistant license current in NYS upon hire required or MD - Doctor of Medicine - MD License current in NYS upon hire required or DO - Doctor of Osteopathic Medicine current DO License in NYS upon hire required

Nice To Haves

• Prior experience with EPARC, eRecord, HDM, and SharePoint preferred.
• Clinical Documentation Specialist (CDS) upon hire preferred or CDIP - Clinical Documentation Improvement Professional upon hire preferred

Responsibilities

• Recognizes gaps and facilitates modifications in clinical documentation that support the accuracy of medical conditions for inpatient encounters.
• Recognizes documentation opportunities with the assistance of computer software.
• Conducts clinical documentation improvement efforts through query processes.
• Provides oversight of EPARC, including UM and unbilled work queues.
• Communicates with individual physicians and medical team, providing guidance and clarification around principle diagnoses, complicating conditions, and diagnoses being treated to ensure complete and accurate documentation in the medical record.
• Presents overall findings to key stakeholders, including leadership and peers.
• Provides education to peers and healthcare team members on documentation improvement, reimbursement opportunities, and overall performance.
• Demonstrates knowledge of trends in clinical diagnoses that result in payer denials.
• Ensures the validity of data for reporting and measuring physician and hospital outcomes through software and data analysis.
• Audits clinical documentation to confirm points of clarification have been entered in the medical record.
• Meets established productivity expectations of the CDI program.
• Maintains knowledge of hospital clinical practice guidelines to support the most thorough review of the medical record.
• Other duties as assigned.

What This Job Offers

• Job Type: Full-time