RN Clinical Documentation Improvement Specialist

Texas Health Huguley FWS; Hinsdale (IL); Hybrid; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a dedicated RN Clinical Documentation Improvement Specialist to enhance patient care through meticulous documentation practices. This role involves collaborating with healthcare professionals to ensure compliance and accuracy in clinical records, contributing to improved patient outcomes. The position offers the opportunity to thrive in a supportive environment that values professional growth and community well-being. Ideal candidates will possess strong communication skills and a commitment to excellence in healthcare documentation. Join a team that prioritizes integrity and quality in every aspect of patient care.

Benefits

Benefits from Day One

Paid Time Off

Student Loan Repayment Program

Whole Person Wellbeing Resources

Mental Health Resources

Paid Parental Leave

Debt-free Education

Qualifications

• Minimum of five years acute care nursing experience required.
• Knowledge of pathophysiology, disease processes, and treatments needed.

Responsibilities

• Facilitates and obtains quality physician documentation for clinical conditions.
• Educates patient care team on documentation guidelines and compliance.

Skills

Interpersonal Skills

Communication Skills

Critical Thinking

Problem Solving

Organizational Skills

Education

Five years acute care nursing experience

BSN or higher

Tools

CDI Software

Multiple Software Programs

Job description

Job Description - RN Clinical Documentation Improvement Specialist (25017152)

Job Description

RN Clinical Documentation Improvement Specialist (

Job Number:

25017152 )

Description

All the benefits and perks you need for you and your family:

· Benefits from Day One for FT/PT positions

· Paid Time Off from Day One for FT/PT positions

· Student Loan Repayment Program for FT/PT positions

· Whole Person Wellbeing Resources

· Mental Health Resources and Support

· Paid Parental Leave (FT positions only)

· Debt-free Education (Certifications and Degrees without out-of-pocket tuition expense)

Our promise to you:

Joining UChicago Medicine AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. UChicago Medicine AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding thattogetherwe are even better.

Location: Remote but must be available for in-person meetings every other month and in-person training/education as needed

The role you’ll contribute:

Under general supervision of the Director of Clinical Documentation Integrity and in some situations the supervision of the Clinical Documentation Integrity Manager, and in collaboration with physicians, nursing and HIM coders, the Clinical Documentation Specialist (CDS) strategically facilitates and obtains appropriate and quality physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. The CDS educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, care management and etc. The CDS adheres to strict departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance.Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

The value you’ll bring to the team:

• Demonstrates extending the healing ministry of Christ, through behavioral whole care standards of love me, make it easy, own it and keep me safe to every person they meet.Delivers exceptional care and strives for excellence.Committed to improving the health, prosperity and well-being of the communities we serve.Uphold the highest standards, with integrity driving every decision made and every action taken. Guided by relentless stewardship in the management of resources entrusted to them.

• Reviews concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM) and quality.

• Completes accurate and timely record review to ensure the integrity of documentation compliance.Completes accurate and concise input of data into CDI Software resulting in accurate metrics obtained through the reconciliation process.Understands and supports CDI documentation strategies (upon completion of didactic training) and continues to educate self and team members, by attending monthly mandated education sessions and using educational tools, videos and provided Webinars

• Recognizes opportunities for documentation improvement using strong critical-thinking skills.Uses critical thinking and sound judgment in decision making keeping quality considerations in balance with regulatory compliance.Initiates/formulates CDI severity worksheets and clinically credible clarifications for inpatients, sending/presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other clinical team members.

• Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs and HACs to ensure documentation compliance is accomplished.

• Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team.This includes quarterly and annual compliance updates from Medicare.

• Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation.Communicates with HIM staff and collaborates with them to resolves discrepancies with DRG assignments and other coding issues.

• Completes well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications.

• Participates in department meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI leaders.

• Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.

• Demonstrates competence in chart audits

• Correctly identifies physician clarification opportunities

• Proficient in formulating valid clarifications that are easily understood by physicians and other members of the medical team.

• Accurately reconciles all cases in CDI database.

• Maintains a 95% physician response rate to all valid clarifications.

• Performs other duties as assigned.

Qualifications

The expertise and experiences you’ll need to succeed:

KNOWLEDGE AND SKILLS REQUIRED

• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations.

• Able to organize and present information clearly and concisely;excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills.

• Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist.

• Dependable, self-motivated and pleasant.

• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills.

• Knowledge of pathophysiology, disease processes and treatments.

• Strong ability to organize/triage work and manage multiple priorities at once.

KNOWLEDGE AND SKILLS PREFERRED

• Knowledge of clinical documentation requirements that identify clinical conditions or procedures.

• Knowledge of quality guidelines.

EDUCATION AND EXPERIENCE REQUIRED

• Minimum of five years acute care nursing experience with specific medical/surgical, Intensive Care, post-acute care unit, or Emergency Department experience.

• Minimum of one year of CDI experience

EDUCATION AND EXPERIENCE PREFERRED

• BSN or higher

• More than one year of Clinical Documentation Specialist experience

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED

• Current active State of Illinois license as a Registered Nurse, Nurse Practitioner, Physician Assistant

LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED

• CCDS (Certified Clinical Documentation Specialist) certification

REQUIRED COMPETENCIES

• AdventHealth online learning (ALN)

• Achieve a 70% or greater on the AdventHealth Corporate Approved Pre-Hire Assessment

• Achieve a 70% or greater on the Annual AdventHealth Corporate Approved Post-Hire Assessment

Job

Job

: Nursing

Organization

Organization

: UChicago Medicine AdventHealth Great Lakes