Clinical Documentation Specialist

University of Iowa • Iowa City, IA

6d • Remote

About The Position

The Clinical Documentation Improvement (CDI) program at UI Health Care has an opening for a full-time Clinical Documentation Specialist. The primary purpose of Clinical Documentation Improvement (CDI) is concurrent review of the medical record to increase the accuracy, clarity, and specificity of provider documentation (Association of Clinical Documentation Improvement Specialists, ACDIS).
Clinical Documentation Specialists bridge the gap between the providers and hospital coders to clarify at-risk documentation to ensure accurate claim submission (American Health Information Management Association, AHIMA). CDI chart reviews include:
New acute inpatient admissions to the facility
Identifies and re-reviews high priority charts every two days or as needed
Retrospective reviews for query identification, documentation clarification, denials, or quality measures.
Completes quality reviews focused on CDI quality elements, such as Mortality, Hospital Acquired Conditions (HAC), and other publicly reported patient quality or safety metrics (i.e., AHRQ Patient Safety Indicators)
When provider documentation is illegible, incomplete, imprecise, inconsistent, conflicting, or unreliable the Clinical Documentation Specialist is expected to communicate (i.e., query) with the provider to obtain the necessary information to clarify the medical record (AHIMA, 2014).
The Clinical Documentation Specialist must hold a general proficiency within both the clinical and hospital coding skill sets. The Clinical Documentation Specialist provides the geometric mean length of stay (GMLOS) associated with the working DRG to identify the expected length of stay for acute inpatients.
The successful candidate will have:
A bachelor’s degree in nursing or a master’s degree in nursing (MNHP or MSN)
An Iowa nursing license
Three years of recent inpatient nursing experience in a medical-surgical, and/or ICU setting, and/or recent work experience as a Clinical Documentation Specialist, CDI nurse, or healthcare quality professional with specific medical record review experience
Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire.
Applicants must upload a current resume and a cover letter that clearly address how they meet the listed required and desired qualifications of this position.
Initial training and onboarding will take place at the Healthcare Support Services Building (HSSB), 3231 Ridgeway Drive, located in Coralville, IA 52241. This position is eligible to participate in 100%25 remote work after the initial training and onboarding has been completed. Remote work must be performed at a location within the state of Iowa and will require a work arrangement form to be completed upon the start of your employment. Per policy, work arrangements will be reviewed annually, and must comply with the remote work program and related policies and the employee travel policy when working at a remote location.

Requirements

• A bachelor’s degree in nursing or a master's degree in nursing (MNHP or MSN) is required.
• A current license to practice nursing in Iowa is required.
• Three years of recent (within the last 10 years) of inpatient nursing experience in a medical-surgical, and/or ICU setting, and/or recent work experience as a Clinical Documentation Specialist, CDI nurse, or healthcare quality professional with specific medical record review experience are required.
• Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire.
• Professional written and verbal communication skills are required
• Demonstrates the ability to provide effective education in a variety of styles, including formal presentations.
• Proficiency with computer software applications (i.e., Microsoft applications) is required
• Demonstrates excellent interpersonal skills with physicians, nursing staff, and interdisciplinary team members as demonstrated through written and verbal communication is required.
• Demonstrated organizational, time management and problem-solving skills are required.

Nice To Haves

• Experience with performance improvement methodologies
• Experience improving and/or reviewing hospital quality/safety metrics
• Experience with data mining and/or data analytics
• Advanced certification (i.e., CCDS, CDIP, CPHQ)

Responsibilities

• Establishes effective and collaborative relationships with members of the hospital community to improve accuracy and completeness of acute inpatient documentation, especially with providers, Health Information Management coding staff, hospital administration, and other patient caregivers.
• Demonstrate knowledge of MS-DRGs, APR-DRGs, documentation opportunities, clinical documentation requirements, and inpatient quality/safety metrics.
• Consistently attends huddles or rounds on units, as directed by department leadership.
• Provides consistent education on clinical documentation opportunities, hospital coding and/or reimbursement issues, as well as performance improvement methodologies to all members of the hospital community.
• Conduct record reconciliation and communicates effectively with hospital coding staff to assign an appropriate working DRG.
• Documents appropriately in the 3M© Clinical Documentation Improvement module.
• Demonstrates an understanding of the importance of capturing all potential secondary diagnosis for coding purposes.
• Maintains thorough and current knowledge of clinical care and treatment of assigned patient populations to critically assess appropriateness of documentation.
• Comply with departmental standards regarding attendance, documentation, departmental workflows, continuous quality improvement and statistics, departmental policies and procedures, and the Code of Ethics.
• Effectively collaborates and respectfully communicates with fellow CDI team members, the hospital coding team, and quality-driven workgroups to ensure appropriate CDI practices and accurate application of coding/documentation principals.
• Actively participate in office and/or intradepartmental committees.
• Performs other projects or responsibilities as assigned.

Benefits

• Fringe benefit package including paid vacation; sick leave; health, dental, life and disability insurance options; and generous employer contributions into retirement plans.
• Complete information regarding the full benefits package may be viewed at: https://hr.uiowa.edu/benefits.

What This Job Offers

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