Clinical Documentation Improvement Specialist (On-Site Only)

Northern Nevada Health System; Sparks (NV); On-site; USD 74,400 - 122,000; Full time

Benefits offered by this job

Competitive Compensation & Generous Paid Time Off

Excellent Medical, Dental, Vision and Prescription Drug Plans

401(K) with company match

Tuition Reimbursement/Repayment Program

Job summary

A regional healthcare provider is seeking a Clinical Documentation Improvement Specialist for an onsite, full-time role. The successful candidate will conduct concurrent reviews of inpatient medical records and collaborate with healthcare professionals to ensure accurate documentation. This position requires a nursing degree and at least five years of clinical experience in an acute care setting, with an active RN license in Nevada. Competitive compensation and full benefits are offered.

Qualifications

• At least five years of clinical experience in an acute care setting.
• CDIS experience preferred.
• Active RN license in Nevada required.

Responsibilities

• Conduct initial and extended-stay concurrent reviews on all selected admissions.
• Utilize inpatient admission criteria to assign appropriate diagnoses.
• Collaborate with healthcare teams to identify diagnoses and procedures.
• Clarify documentation in medical records with healthcare professionals.
• Monitor progress of the DRG Assurance program through data analysis.

Skills

Clinical experience in an acute care setting

Communication skills

Collaboration with healthcare professionals

Attention to detail

Education

Associates or Bachelor's Degree in Nursing Education

Current RN license in the State of Nevada

Job description

Clinical Documentation Improvement Specialist (On-Site Only)

Northern Nevada Health System provided pay range. This range is provided by Northern Nevada Health System. Your actual pay will be based on your skills and experience — talk with your recruiter to learn more.

Base pay range

$74,400.00/yr - $122,000.00/yr

When it comes to choosing a hospital, one thing is clear: quality and convenience count. Northern Nevada Medical Center's tradition of providing quality healthcare in a comfortable, accessible environment means peace of mind for the thousands of patients served by the hospital each year. Northern Nevada Medical Center is a 124-bed acute care hospital located on 23 hillside acres at 2375 E. Prater Way in Sparks, Nevada.

RELOCATION OFFERED

This CDIS, Clinical Documentation Improvement Specialist on-site only opportunity is full time @ 40 hours per week, offers full benefits and a convenient flexible schedule. This individual will provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality. Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.

Job Duties/Responsibilities:

• Conduct initial and extended-stay concurrent reviews on all selected admissions, and document findings within CDIS (electronic review system), denoting all key information (including working DRG and queries) utilized in the tracking process.
• Utilize inpatient admission criteria to assign only diagnoses that meet acute care criteria. In the event that a diagnosis does not meet admission criteria, communicate with Case Management Department to determine the appropriate patient status.
• Collaborate with physician, physician extender, nurse, case manager/utilization review, and HIM coder to identify principal diagnosis options, secondary diagnoses including complications and comorbidities, and procedures, to assign working DRGs for at least 80%-85% of the identified populations.
• Identify need to clarify documentation in medical records and utilize strong communication skills with physician, physician extender, case manager, utilization review, nurse or other healthcare professional, utilizing appropriate tools to capture needed documentation.
• Utilize monitoring tools to track the progress of the DRG Assurance program, through interpretation of the CDIS tracking reports, monitoring reports and data. Identify areas of focus through report analysis. Serve as a resource to physicians and Administration regarding issues related to the appropriateness of inpatient DRG assignment.

Benefits for full and part time employees:

• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• Tuition Reimbursement/Repayment Program
• Career development opportunities within UHS and its 300+ Subsidiaries!
• More information is available on our Benefits Guest Website: benefits.uhsguest.com

Requirements:

• Associates or Bachelor's Degree in Nursing Education or International Medical Graduate.
• Minimum of five (5) years of clinical experience in an acute care setting; critical care, medical/surgical or Emergency Department nursing preferred.
• Prefer CDIS Experience preferred.
• Current RN license in the State of Nevada.

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.

Job Details

• Seniority level: Associate
• Employment type: Full-time
• Job function: Health Care Provider
• Industries: Hospitals and Health Care