Nurse CDI Specialist: Elevate Clinical Documentation

Utah; Salt Lake City (UT); Hybride; USD 90 000 - 120 000; Plein temps

Résumé du poste

University of Utah Health seeks a Clinical Documentation Improvement Specialist to enhance the quality and completeness of medical record documentation across care teams. The role collaborates with physicians, case managers, coders and nursing staff to reflect clinical treatment and diagnoses for patients, enabling appropriate reimbursement and quality reporting.

The position emphasizes education, coordination with coding and continuous process improvement in a Hospital/Health system setting.

Qualifications

• Five years of clinical and critical nursing experience.
• Bachelor's degree in Nursing or equivalency.

Responsabilités

• Ensures documentation meets quality standards and an accurate reflection of the patient's status in the medical record.
• Provides education to staff and physicians on the Clinical Documentation Improvement Program (CDIP).
• Facilitates modifications to clinical documentation with physicians, nursing staff and coding to support appropriate reimbursement and clinical severity.
• Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
• Assists the assigned coder with reviewing medical records of inpatients and discusses documentation opportunities with physician teams.
• Acts as consultant to coders when additional information or documentation is needed to assign the correct DRG.
• Participates in hospital, unit and departmental committees.
• May require rotating schedules including nights, weekends, and holidays to meet staffing needs.

Connaissances

Clinical documentation

Education of staff

Interdisciplinary collaboration

Communication skills

Formation

Bachelor's degree in Nursing or equivalency

Five years of clinical and critical nursing experience

Description du poste

University of Utah Health seeks a Clinical Documentation Improvement Specialist to enhance the quality and completeness of medical record documentation across care teams. The role collaborates with physicians, case managers, coders and nursing staff to reflect clinical treatment and diagnoses for patients, enabling appropriate reimbursement and quality reporting.

The position emphasizes education, coordination with coding and continuous process improvement in a Hospital/Health system setting.