Documentation Improvement Coordinator

University Health; Boerne (TX); On-site; USD 75,000 - 105,000; Full time

Job summary

University Health in Texas is seeking a Clinical Documentation Improvement Nurse to ensure accurate and complete documentation for inpatients. You will review patient charts, query providers, and collaborate with the care team to reflect ROM and SOI for optimum reimbursement.

Requirements include a bachelor's degree in nursing, Texas RN license, and several years hospital experience; completion of a Clinical Documentation Improvement course within hire date.

Qualifications

• Bachelor's degree in nursing preferred.
• Three years recent, full-time hospital experience preferred.
• Work experience in documentation improvement, case management, utilization review or hospital quality assurance preferred.
• Must complete a Clinical Documentation Improvement Course within specified time of hire date.

Responsibilities

• Review inpatient charts to ensure accurate and complete documentation.
• Query providers to ensure complete documentation in the medical record.
• Collaborate with the care team to reflect ROM and SOI for appropriate reimbursement.
• Maintain knowledge of coding guidelines, ACDIS standards, Epic workflows, and 3M principles.

Skills

Clinical Documentation Improvement

Education

Bachelor's degree in nursing

RN license

Job description

POSITION SUMMARY/RESPONSIBILITIES:

Must be clinically competent in caring for the assigned inpatient population. Must work collaboratively with all members of the healthcare team. Reviews patient accounts through the appropriate review process for accurate and complete documentation of the care of the patient. Queries the provider to ensure that the accurate and complete documentation is recorded in the medical record. Concurrently reviews the documentation of the patients care and queries as appropriate following the ACDIS/AHIMA query brief guidelines to ensure complete and accurate documentation of a patient's care during their stay in the hospital. Promotes accurate documentation that reflects the appropriate risk of mortality (ROM) and severity of illness (SOI) resulting in maximum reimbursement. Maintains a strong understanding and knowledge of coding guidelines, ACDIS standards, Epic workflows, and 3M principles.

EDUCATION/EXPERIENCE

Graduation from an accredited college or university with a bachelor's degree in nursing is preferred. Three years recent, full-time hospital experience preferred. Work experience in documentation improvement, case management, utilization review or hospital quality assurance is preferred. Must complete a Clinical Documentation Improvement Course within specified time of hire date.

LICENSURE/CERTIFICATION

Current license from the Board of Nurse Examiners of the State of Texas to practice as a registered nurse; National certification (e.g. CDS, CCRN, RNC, CEN, CNOR, OCN, ANCC, CAN, CPAN, CFRN, etc.) in related field is preferred.