LEAD CLINICAL DOCUMENTATION COORD/GME - VALLEY HOSPITAL (FULL-TIME)

The Valley Health System; Florida; On-site; USD 90,000 - 120,000; Full time

Benefits offered by this job

Competitive compensation

Generous paid time off

Medical, dental, vision plans

401(k) with company match

Education and training center

Job summary

The Valley Health System is seeking a Clinical Documentation Integrity lead to manage the CDI program for GME and medical staff education. The role includes guiding concurrent and retrospective reviews of inpatient records to ensure accurate documentation of services and optimal reimbursement.

Ideal candidates will be seasoned RNs with CDI experience, strong analytical skills, and proficiency with EHR and coding software.

Qualifications

• Must hold an RN license in the state of residence.
• Minimum 2 years of clinical experience in acute care settings; 1 year CDI experience preferred.
• Knowledge of PPS/DRG optimization is required.
• Management experience is strongly preferred but not required.

Responsibilities

• Oversee day-to-day workflow of the Clinical Documentation Integrity Program for GME and medical staff education.
• Conduct concurrent and retrospective reviews of inpatient records to evaluate utilization and documentation of acute care services.
• Facilitate accurate physician documentation of care to reflect patient severity and risk of mortality.
• Prepare reports on quality of care outcomes and reimbursement impact for external payers and regulators.

Skills

Clinical experience

Critical thinking

Communication skills

EHR proficiency

CDI knowledge

Education

Associate’s degree in nursing

Bachelor’s degree in nursing preferred

Graduate of medical school

Tools

CDI/Coding software

Electronic Health Records (EHR) systems

Word processing & spreadsheets

Databases

Job description

Responsibilities

The Valley Health System has expanded into an integrated health network that serves more than two million people in Southern Nevada. Starting with Valley Hospital Medical Center in 1979, the Valley Health System has grown to include Centennial Hills Hospital Medical Center, Spring Valley Hospital Medical Center, Summerlin Hospital Medical Center Henderson Hospital, Valley Health Specialty Hospital, and West Henderson Hospital.

Benefit Highlights

Competitive Compensation & Generous Paid Time OffExcellent Medical, Dental, Vision and Prescription Drug Plans401(K) with company match and discounted stock planCareer opportunities within VHS and UHS SubsidiesChallenging and rewarding work environmentComprehensive education and training center

Job Description

Under the supervision of the Regional Manager CDI manages day-to-day workflow, specifically the operations of the Clinical Documentation Integrity Program for GME and medical staff education. This position is also responsible for providing 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 determined both 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.

Qualifications

Education: Associate’s degree in nursing; bachelor’s degree in nursing preferred or a Graduate of a domestic/international school of medicine.Experience: For Registered Nurse, a minimum of two (2) years of clinical experience in an acute care setting (critical care, surgical or emergency department nursing preferred), and a minimum of 1-year previous clinical documentation integrity experience (2-3 years of previous clinical documentation integrity experience preferred). Knowledge of the Prospective Payment System and Diagnosis Related Group selection, assignment and optimization are required.For Domestic/International Medical Graduate: A minimum of 1-year previous clinical documentation integrity experience (2-3 years of previous clinical documentation integrity experience preferred). Knowledge of the Prospective Payment System and Diagnosis Related Group selection, assignment and optimization are required. Minimum of 1-year management experience strongly preferred but not required.Technical Skills: Computer proficiency to include word processing, databases, and spreadsheets. Familiarity with the operation of basic office equipment. Basic competence in use of electronic health records and other CDI/Coding software applications.License/Certification: If Registered Nurse, current RN license in their state of residence.Preferred certifications: CDIP, CCDS, CCS and/or ICD-10 Certification or Trainer designation.

Other

Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes. Knowledge of age-specific needs and elements of disease processes and related procedures required. Working knowledge of inpatient admission criteria.Medicare reimbursement system and coding systems required. Must possess excellent written and verbal communication skills and critical thinking skills. Ability to work independently in a time-oriented environment is essential.

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.