Clinical Documentation Improvement Specialist-RN

University of Arkansas for Medical Sciences • Little Rock, AR

1d

About The Position

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.

Requirements

• 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.

Nice To Haves

• Current CCDS

Responsibilities

• 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.

Benefits

• Medical, Dental and Vision plans available for qualifying staff and family
• Holiday, Vacation and Sick Leave
• Education discount for staff and dependents (undergraduate only)
• Up to 10% matched contribution from UAMS
• Basic Life Insurance up to $50,000
• Career Training and Educational Opportunities
• Merchant Discounts
• Concierge prescription delivery on the main campus when using UAMS pharmacy

What This Job Offers

• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees