CDI Nurse Specialist: Elevate Medical Documentation

University of Utah Health; Salt Lake City (UT); On-site; USD 85,000 - 110,000; Full time

Job summary

University of Utah Health is seeking a Clinical Documentation Improvement professional to enhance the quality and completeness of patient medical records by educating physicians, case managers, coders and the health team. This role supports accurate reimbursement and clinical severity through CDI collaboration.

The position requires a Registered Nurse with five years of clinical and critical nursing experience and a Bachelor's degree in Nursing or equivalency.

Qualifications

• Five years of clinical and critical nursing experience.
• Bachelor's degree in Nursing or equivalency.
• Knowledge of ICD-9 and DRG.

Responsibilities

• Ensures documentation meets quality standards and an accurate reflection of the patient's status is entered in the medical record.
• Provides education to staff and physicians on the Clinical Documentation Improvement Program (CDIP).
• Facilitates modifications to clinical documentation with physicians, nursing staff and coding to support appropriate reimbursement and clinical severity.
• Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
• Assists the assigned coder with reviewing medical records of inpatients and discusses documentation opportunities with physician teams.
• Acts as consultant to coders when additional information or documentation is needed to assign the correct DRG.
• Participates in hospital, unit and departmental committees.
• Rotating schedules including nights, weekends, holidays to meet staffing demands; punctual attendance is essential.

Skills

Clinical nursing

Documentation improvement

Education & training

Collaboration

Education

Nursing Bachelor’s degree or equivalency

5 years clinical and critical nursing experience

Job description

University of Utah Health is seeking a Clinical Documentation Improvement professional to enhance the quality and completeness of patient medical records by educating physicians, case managers, coders and the health team. This role supports accurate reimbursement and clinical severity through CDI collaboration.

The position requires a Registered Nurse with five years of clinical and critical nursing experience and a Bachelor's degree in Nursing or equivalency.