Documentation Improvement Coordinator

University Health; Seguin (TX); On-site; USD 70,000 - 90,000; Full time

Job summary

University Health is seeking a clinically proficient registered nurse focused on clinical documentation improvement. You will collaborate with the healthcare team to review patient accounts, query providers, and ensure complete documentation reflecting ROM and SOI for optimal reimbursement.

ACDIS and AHIMA standards, along with Epic workflows and 3M principles, guide practice. Preferred is a Bachelor's in Nursing with hospital CDI experience and completion of a CDI course within hire, along with

Qualifications

• Bachelor's degree in nursing preferred.
• Three years hospital experience preferred.
• Experience in documentation improvement, case management, utilization review or quality assurance preferred.
• Clinical Documentation Improvement Course within hire date.

Responsibilities

• Review patient accounts for accurate documentation of care.
• Query providers to ensure accurate documentation in the medical record.
• Review documentation to ensure completeness and appropriate ROM/SOI for maximum reimbursement.
• Maintain knowledge of coding guidelines, ACDIS standards, Epic workflows, and 3M principles.

Skills

Clinical documentation

Team collaboration

Querying providers

Coding guideline knowledge

Education

Bachelor's degree in nursing

Tools

Epic

3M coding

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.