Clinical Documentation Spec RN

Description

Clinical Documentation Specialist RN

Location : UCHealth Leprino Building AMC, US : CO : Aurora

Department : Clinical Documentation Integrity

FTE : Full Time, 1.0, 80.00 hours per pay period (2 weeks)

Shift : Days

Pay : $37.06 - $57.44 / hour. Pay is dependent on applicant's relevant experience

Summary :

Performs concurrent review of clinical documentation in written and electronic medical records to ensure compliant, appropriate and accurate reimbursement based on severity of patient illness, risk of mortality and level of services provided to patients. Collaborates with physicians, nursing staff, ancillary departments, and coding staff to ensure clinical documentation is compliant, complete and accurate. Provides ongoing education and support to the healthcare team in regard to clinical documentation in the medical record. Qualified / eligible out-of-state applicants may be considered.

Responsibilities :

Reviews inpatient medical records for areas of opportunity regarding clinical documentation of diagnosis and procedures to assign a working DRG for identified population. Conducts reviews and documents findings.

Identifies need to clarify documentation in records; communicates with providers to capture documentation that supports the severity of illness and risk of mortality. Conducts follow up reviews for responses to physician queries. Serves as a resource to physicians and staff.

Works with coding staff to assure documentation of diagnoses and comorbidities or complications are a complete reflection of the patient's clinical status and care.

Maintains knowledge of requirements and guidelines to include changes / updates to practice or requirements.

Within scope of job, requires critical thinking skills, decisive judgement and the ability to work with minimal supervision. Must be able to work in a fast-paced environment and take appropriate action.

Requirements :

• Minimum Required Education : Graduate of an accredited or state board of nursing approved Registered / Professional Nursing program.
• Required Licensure / Certification : State licensure as a Registered Nurse (RN).

Minimum Experience : 5 years of recent clinical experience in an acute inpatient nursing unit OR current work experience that requires communication with providers, with 5 years of nursing in an acute care facility. Preferred : Critical care and MED / SURG background with the ability to assess and identify relevant acute and chronic medical conditions. CDI experience.

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Loan Repayment :

UCHealth always welcomes talent. This position will be open for a minimum of three days and until a top applicant is identified.

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