Quality & Operational Improvement Engineer - Clinical Documentation Improvement

The University of Iowa; Iowa City (IA); Hybrid; USD 75,000 - 95,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Life insurance

Disability insurance

Retirement plans

Paid time off

Job summary

The University of Iowa Health Care is seeking a Quality & Operational Improvement Engineer - Clinical Documentation Improvement for a full-time CDI Specialist role. This position bridges clinicians and coders to clarify documentation and improve claim accuracy, with a focus on CDI quality elements and DRG accuracy.

Ideal candidates hold a nursing degree (RN) and CDI experience, plan to obtain CCDS certification within 3 years, and may work remotely after initial training in Iowa.

Qualifications

• A bachelor’s degree in nursing or a master’s degree in nursing is required.
• A current license to practice nursing in Iowa is required.
• Previous CDI experience within the last 5 years is required.
• CCDS certification must be obtained within 3 years of hire.
• Professional written and verbal communication skills are required.
• Ability to educate in varied styles, including formal presentations.
• Proficiency with Microsoft Office or similar software is required.
• Excellent interpersonal skills with physicians and staff are required.
• Strong organizational, time management and problem-solving abilities.

Responsibilities

• Establish collaborative relationships to improve accuracy and completeness of inpatient documentation.
• Demonstrate knowledge of MS-DRGs, APR-DRGs, documentation opportunities and quality metrics.
• Attend huddles or rounds on units as directed by leadership.
• Provide education on CDI opportunities and coding/reimbursement issues.
• Conduct record reconciliation and communicate with coding staff to assign working DRGs.
• Safely capture all potential secondary diagnoses for coding purposes.
• Maintain up-to-date knowledge of clinical care to assess documentation appropriateness.
• Comply with standards, workflows, QA, and departmental policies.
• Collaborate with CDI team members and quality workgroups to ensure proper practices.
• Participate in committees and perform other assigned projects.

Skills

Interpersonal skills

Communication skills

Time management

Problem-solving

Education delivery

Education

Bachelor's degree in nursing

Master's degree in nursing (MNHP or MSN)

Tools

Microsoft Office

Job description

Quality & Operational Improvement Engineer - Clinical Documentation Improvement

The Clinical Documentation Improvement (CDI) program at UI Health Care has an opening for a full time (100%) Clinical Documentation Specialist. The primary purpose of Clinical Documentation Improvement (CDI) is concurrent review of the medical record to increase the accuracy, clarity, and specificity of provider documentation (Association of Clinical Documentation Improvement Specialists, ACDIS).

Clinical Documentation Specialists bridge the gap between the providers and hospital coders to clarify at-risk documentation to ensure accurate claim submission (American Health Information Management Association, AHIMA). CDI chart reviews include:

• New acute inpatient admissions to the facility
• Identifies and re-reviews high priority charts every two days or as needed
• Retrospective reviews for query identification, documentation clarification, denials, or quality measures.
• Completes quality reviews focused on CDI quality elements, such as Mortality, Hospital Acquired Conditions (HAC), and other publicly reported patient quality or safety metrics (i.e., AHRQ Patient Safety Indicators)
• When provider documentation is illegible, incomplete, imprecise, inconsistent, conflicting, or unreliable the Clinical Documentation Specialist is expected to communicate (i.e., query) with the provider to obtain the necessary information to clarify the medical record (AHIMA, 2014).

The Clinical Documentation Specialist must hold a general proficiency within both the clinical and hospital coding skill sets. The Clinical Documentation Specialist provides the geometric mean length of stay (GMLOS) associated with the working DRG to identify the expected length of stay for acute inpatients.

The successful candidate will have

• A bachelor’s degree in nursing or a master’s degree in nursing (MNHP or MSN)
• Previous work experience (within the last 5 years) as a Clinical Documentation Specialist
• Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire.

Initial training and onboarding will take place at the Healthcare Support Services Building (HSSB), 3231 Ridgeway Drive, located in Coralville, IA 52241. This position is eligible to participate in 100% remote work after the initial training and onboarding has been completed. Remote work must be performed at a location within the state of Iowa and will require a work arrangement form to be completed upon the start of your employment. Per policy, work arrangements will be reviewed annually and must comply with the remote work program and related policies and the employee travel policy when working at a remote location .

Job Duties and Responsibilities

• Establishes effective and collaborative relationships with members of the hospital community to improve accuracy and completeness of acute inpatient documentation, especially with providers, Health Information Management coding staff, hospital administration, and other patient caregivers.
• Demonstrate knowledge of MS-DRGs, APR-DRGs, documentation opportunities, clinical documentation requirements, and inpatient quality/safety metrics.
• Consistently attend huddles or rounds on units, as directed by department leadership.
• Provides consistent education on clinical documentation opportunities, hospital coding and/or reimbursement issues, as well as performance improvement methodologies to all members of the hospital community.
• Conduct record reconciliation and communicates effectively with hospital coding staff to assign an appropriate working DRG.
• Demonstrates an understanding of the importance of capturing all potential secondary diagnosis for coding purposes.
• Maintains thorough and current knowledge of clinical care and treatment of assigned patient populations to critically assess appropriateness of documentation.
• Comply with departmental standards regarding attendance, documentation, departmental workflows, continuous quality improvement and statistics, departmental policies and procedures, and the Code of Ethics.
• Effectively collaborates and respectfully communicates with fellow CDI team members, the hospital coding team, and quality-driven workgroups to ensure appropriate CDI practices and accurate application of coding/documentation principals.
• Actively participate in office and/or intradepartmental committees.
• Performs other projects or responsibilities as assigned.

This position does not have direct patient care responsibilities.

Percent of Time

100% (Full Time)

Work schedule

Flexible between the hours of 8:00 AM 4:30 PM, Monday through Friday.

Benefits Highlights

• Fringe benefit package including paid vacation; sick leave; health, dental, life and disability insurance options; and generous employer contributions into retirement plans. Complete information regarding the full benefits package may be viewed at: https://hr.uiowa.edu/benefits.

About University of Iowa Health Care

UI Health Care is recognized as one of the best hospitals in the United States and is Iowa’s only comprehensive academic medical center and a regional referral center. Each day more than 12,000 employees, students, and volunteers work together to provide safe, quality health care and excellent service for our patients. Simply stated, our mission is: Changing Medicine. Changing Lives.®

Qualifications - External

Required Qualifications

• A bachelor’s degree in nursing or a master’s degree in nursing (MNHP or MSN), or an equivalent combination of education in a related field and experience is required.
• A current license to practice nursing in Iowa is required.
• Previous work experience (within the last 5 years) as a Clinical Documentation Specialist is required.
• Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire.
• Professional written and verbal communication skills are required
• Demonstrates the ability to provide effective education in a variety of styles, including formal presentations.
• Proficiency with computer software applications (i.e., Microsoft applications) is required
• Demonstrates excellent interpersonal skills with physicians, nursing staff, and interdisciplinary team members as demonstrated through written and verbal communication is required.
• Demonstrated organizational, time management and problem-solving skills are required.

Desired Qualifications

• Experience with performance improvement methodologies
• Experience improving and/or reviewing hospital quality/safety metrics
• Experience with data mining and/or data analytics
• Advanced certification (i.e., CCDS, CDIP, CPHQ)

Additional Information

• Classification Title: Qual & Op Improv Engineer
• Appointment Type: Professional and Scientific
• Schedule: Full-time
• Work Modality Options: Hybrid within Iowa

Compensation

Contact Information

Equal opportunity employer

The University of Iowa is an equal opportunity employer. All qualified applicants are encouraged to apply and will receive consideration for employment free from discrimination on the basis of race, creed, color, religion, national origin, age, sex, pregnancy (including childbirth and related conditions), disability, genetic information, status as a U.S. veteran, service in the U.S. military, sexual orientation, or associational preferences.

Persons with disabilities who need assistance or accommodations with the application or interview process may contact University Human Resources/Faculty and Staff Disability Services, [phone] or [e-mail] . For jobs in UI Health care, please contact UI Health care Leave & Disability Administration at 319-356-7543 .

Successful candidates will be required to self-disclose any conviction history and will be subject to a criminal background check.

Professional references will be requested at a later step in the recruitment process.

This position is not eligible for University of Iowa sponsorship for employment authorization.

For additional questions, please contact Jessica Lanham at [e-mail].