Clinical Document Specialist (RN), Corporate Coding Services, Full Time, First Shift

UC Health; Cincinnati (OH); On-site; USD 70,000 - 100,000; Full time

Job summary

UC Health is hiring a Full Time Clinical Documentation Improvement Specialist for Corporate Coding Services. This role collaborates with physicians to ensure accurate clinical documentation reflecting the level of service and acuity, with follow-up reviews when needed.

CDI staff interface with HIM Coding and education to drive revenue cycle improvements. The ideal candidate will be a registered nurse with Ohio licensure, CDI experience preferred, and a track record of improving documentation

Qualifications

• Registered Nurse from an accredited school is required; Ohio RN license.
• BSN is preferred but not required.
• At least two years CDI experience preferred; or three years acute inpatient med/surg, case management/UR, or clinical auditor experience.

Responsibilities

• Conduct concurrent review of inpatient records to ensure acuity and diagnoses are accurately reflected.
• Complete documentation clarification communications when physician queries are needed.
• Follow up to ensure physician review and response to clarification requests.
• Collaborate with CDI leadership to address documentation issues and trends as needed.
• Provide ongoing educational updates to physicians on documentation and revenue cycle rules.

Skills

Registered Nurse

CDI experience

Acute inpatient med/surg

Education

RN license in Ohio

BSN preferred

Job description

Job Description

UC Health is hiring a Full Time Clinical Documentation Improvement Specialist for Corporate Coding Services

The Clinical Documentation Improvement Specialist will work with physicians to facilitate appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record. Conducts follow-up reviews to ensure that clinical documentation clarified with the physician has been recorded in the medical record, and has been coded by the hospital HIM Coding staff.

About UC Health

UC Health is an integrated academic health system serving Greater Cincinnati and Northern Kentucky. In partnership with the University of Cincinnati, UC Health combines clinical expertise and compassion with research and teaching - a combination that provides patients with options for even the most complex situations. Members of UC Health include: UC Medical Center, West Chester Hospital, University of Cincinnati Physicians and UC Health Ambulatory Services (with more than 900 board-certified clinicians and surgeons), Lindner Center of HOPE and several specialized institutes including: UC Gardner Neuroscience Institute and the University of Cincinnati Cancer Center. Many UC Health locations have received national recognition for outstanding quality and patient satisfaction. Learn more at uchealth.com.

Location

United States

Qualifications

• Registered Nurse from an accredited school of Nursing, College or University required.
• Bachelor of Science in Nursing (BSN) preferred, but not required. | Current RN License in Ohio |
• At least two years CDI experience preferred. Will accept at least three years acute inpatient med/surg experience, case management/UR experience, or clinical auditor experience.

At UC Health, we're proud to have the best and brightest teams and clinicians collaborating toward our common purpose: to advance healing and reduce suffering.

As the region's adult academic health system, we strive for innovation and provide world-class care for not only our community, but patients from all over the world. Join our team and you'll be able to develop your skills, grow your career, build relationships with your peers and patients, and help us be a source of hope for our friends and neighbors. UC Health is an EEO employer.

Responsibilities

• Conducts concurrent review of inpatient medical records on assigned units to ensure that the acuity of care and specificity of diagnoses are accurately reflected in the medical record.
• Completes Documentation Clarification communication tool when physician needs to be queried around clinical documentation issues.
• Conducts follow-up review to ensure physician review and response to these clarification requests.
• Works with department Director and hospital Medical Directors to elevate identified medical staff documentation issues, trends and medical staff compliance issues as needed.
• Acts as adhoc coverage for CDI staff at other UC Health hospitals, as needed.
• Provides ongoing educational updates to physicians on documentation and revenue cycle rules and regulations.
• Enters information into appropriate databases as required to be used for statistical and performance improvement reporting purposes.
• Works with hospital HIM Coding staff to ensure documentation clarifications have been reviewed and coded appropriately as part of the revenue cycle process.
• Assists with the orientation, coaching and mentoring of new CDI associates, as needed.
• Stays abreast of clinical documentation improvement resources to facilitate process efficiencies and educational needs.