Clinical Doc Improvement Spec. (Peds)
About The Position
St. Louis Children's Hospital is seeking a Clinical Documentation Improvement Specialist. The Clinical Documentation Improvement Specialist II (CDIS II) uses clinical and coding knowledge to conduct clinically based concurrent and retrospective reviews of inpatient and outpatient medical records and evaluate the clinical documentation of services. The role identifies opportunities to improve medical record documentation and facilitates appropriate physician documentation of clinical conditions and procedures to support the patient's severity of illness, expected risk of mortality, and complexity of care. The CDIS II contributes to content development and provider education, supports ongoing service-line documentation improvement initiatives, and participates in department and organization projects related to documentation improvement. The role also analyzes clinical and financial information to help ensure accurate and complete medical record documentation.
Requirements
- Nursing diploma or associate's degree in nursing.
- 5–10 years of experience.
- Registered Nurse (RN) license.
- Strong assessment and critical-thinking skills.
- Previous experience working in a pediatric ICU.
Nice To Haves
- Bachelor's degree in nursing.
Responsibilities
- Engages providers and establishes relationships to foster shared accountability for clinical documentation improvement efforts.
- Uses aggregated data and information to identify trends, variances, deficiencies, and problems within the documentation improvement program; conducts provider- and group-level trend analysis and proposes solutions to leadership.
- Contributes to ongoing service-line documentation improvement initiatives and formal and informal provider education plans.
- Contributes to provider education content development and may present educational content based on analysis of clinical and financial information from internal and external sources.
- Participates in formal and informal education activities, including content creation, approval facilitation, meeting scheduling and frequency management, participation, and potentially content delivery for assigned service lines.
- Participates in department and organization projects related to documentation improvement.
- Conducts concurrent and retrospective reviews of inpatient and outpatient medical records to identify opportunities for improved clinical documentation and obtain appropriate physician documentation.
Benefits
- Comprehensive medical, dental, vision, life insurance, and legal services available on the first day of the month after hire.
- Disability insurance paid for by BJC.
- Annual 4% BJC automatic retirement contribution.
- 401(k) plan with BJC match.
- Tuition assistance available on the first day.
- BJC Institute for Learning and Development.
- Health care and dependent care flexible spending accounts.
- Paid time off combining vacation, sick days, holidays, and personal time.
- Adoption assistance.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
