Senior Clinical Documentation Specialist, PRN

Vanderbilt University Medical Center • Nashville, TN

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About The Position

Vanderbilt University Medical Center (VUMC) is seeking a Senior Clinical Documentation Specialist, PRN, to join their team in Nashville, Tennessee. VUMC is dedicated to advancing health and wellness through patient care, education, and research, fostering an environment where employees can thrive and their uniqueness is celebrated. This role is part of the HIM - CDE department and is responsible for ensuring the capture of discharge diagnoses and procedures, documenting the patient's clinical status and care, and performing concurrent review of patient records to support clinical coding. The organization emphasizes collaboration, professional growth, and a sense of community and purpose.

Requirements

• Graduate of an approved discipline specific program
• 3 years of relevant work experience
• LIC-Registered Nurse - Licensure-Others
• Written Communication (Novice): Demonstrates the ability to write clear, detailed, and comprehensive status reports, memos and documentation. Demonstrates an understanding of effective composition, such as having first line in a paragraph state the subject.
• Verbal Communication (Novice): Ability to enunciate clearly, using appropriate voice control and body language. Effectively transmits technical and business ideas and information to others. Listens carefully to ascertain points being made before trying to be understood.
• Medical Coding (Intermediate): The transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.
• Critical Thinking (Novice): The objective analysis and evaluation of an issue in order to form a judgment.
• Relationship Management: Manages internal and external organizational relationships with clients, vendors, partners and staff.
• Organizational Impact: Independently delivers on objectives with understanding of how they impact the results of own area/team and other related teams.
• Problem Solving/ Complexity of work: Utilizes multiple sources of data to analyze and resolve complex problems; may take a new perspective on existing solution.
• Breadth of Knowledge: Has advanced knowledge within a professional area and basic knowledge across related areas.
• Team Interaction: Acts as a "go-to" resource for colleagues with less experience; may lead small project teams.
• Supporting Colleagues: Develops Self and Others: Invests time, energy, and enthusiasm in developing self/others to help improve performance and gain knowledge in new areas.
• Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships.
• Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences.
• Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them.
• Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions.
• Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness.
• Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly.
• Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them.
• Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring.
• Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure.
• Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area.
• Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities.
• Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches.
• Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges.
• Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.

Responsibilities

• Performs assessment of patient records to evaluate documentation for accuracy, legibility, and completeness.
• Works with coding staff to ensure documentation of discharge diagnoses, including any coexisting co-morbidities, and procedures are complete.
• Communicates with providers regarding missing, unclear, or conflicting clinical documentation.
• Collaborates with case managers, nursing staff, and other staff on documentation issues and resolves provider queries prior to patient discharge.
• Monitors provider documentation queries for timely and compliant response and escalates issues.
• Ensures capture of discharge diagnosis and procedures independently.
• Documents the patient's clinical status and care provided.
• Performs concurrent review of patient records for documentation to support assignment of clinical codes.

Benefits

• health
• disability
• retirement
• wellness offerings

What This Job Offers

• Career Level: Senior
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees