Documentation Improvement Coordinator

University Health; Pleasanton (TX); On-site; USD 70,000 - 100,000; Full time

Job summary

University Health is seeking a clinically competent RN with CDI experience to collaborate with the care team and review patient accounts for accurate documentation. You will query providers to ensure precise medical records and adhere to ACDIS/AHIMA guidelines to reflect ROM and SOI for optimal reimbursement.

The role requires knowledge of coding guidelines, ACDIS standards, Epic workflows, and 3M principles.

Qualifications

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

Responsibilities

• Clinically competent in caring for the assigned inpatient population.
• Collaborate with the healthcare team.
• Review patient accounts for accurate and complete documentation of care.
• Query providers to ensure complete documentation in medical records.
• Adhere to ACDIS/AHIMA query guidelines for accurate documentation during hospital stay.
• Promote documentation reflecting ROM and SOI for maximum reimbursement.
• Maintain knowledge of coding guidelines, ACDIS standards, Epic workflows and 3M principles.

Skills

Clinical documentation improvement

Case management

Utilization review

Hospital quality assurance

Epic workflows

ACDIS standards

3M principles

Education

Bachelor's degree in Nursing

Tools

Epic workflows

3M principles

ACDIS standards

Utilization review software

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.