Documentation Improvement Coordinator

University Health; San Antonio (TX); On-site; USD 85,000 - 100,000; Full time

Job summary

University Health is seeking a clinically competent Registered Nurse for clinical documentation improvement within its inpatient units. You will collaborate with the healthcare team to ensure accurate documentation and appropriate coding reflects the patient’s care and outcomes.

The role requires engagement with ACDIS/AHIMA guidelines, ROM and SOI considerations, and ongoing knowledge of Epic workflows and 3M principles to maximize reimbursement and care quality.

Qualifications

• Bachelor's degree in nursing required or preferred.
• Three years recent, full-time hospital experience preferred.
• Clinical Documentation Improvement course within specified time of hire.

Responsibilities

• Care for the assigned inpatient population with clinical competence.
• Review patient accounts for accurate documentation and query providers as needed.
• Query per ACDIS/AHIMA guidelines to ensure complete documentation during the stay.
• Promote documentation reflecting ROM and SOI for maximum reimbursement.
• Maintain knowledge of coding guidelines, ACDIS standards, Epic workflows and 3M principles.

Education

Bachelor's degree in nursing

Tools

Epic workflows

3M principles

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.