Clinical Documentation Specialist 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. This is a 100% remote position. Eligible out-of-state candidates 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 :

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

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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UCHealth offers a Three Year Incentive Bonus to recognize employee's contributions to our success in quality, patient experience, organizational growth, financial goals, and tenure with UCHealth. The bonus accumulates annually each October and is paid out in October following completion of three years' employment.

UCHealth offers their employees a competitive and comprehensive total rewards package (benefit eligibility is based off of FTE status) :

Loan Repayment :

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

UCHealth recognizes and appreciates the rich array of talents and perspectives that equal employment and diversity can offer our institution. As an equal opportunity employer, UCHealth is committed to making all employment decisions based on valid requirements. No applicant shall be discriminated against in any terms, conditions or privileges of employment or otherwise be discriminated against because of the individual's race, color, national origin, language, culture, ethnicity, age, religion, sex, disability, sexual orientation, gender, veteran status, socioeconomic status, or any other characteristic prohibited by federal, state, or local law. UCHealth does not discriminate against any qualified applicant with a disability as defined under the Americans with Disabilities Act and will make reasonable accommodations, when they do not impose an undue hardship on the organization.

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