(RN) Clinical Documentation Specialist

Uconn Health Center; Farmington (CT); On-site; USD 70,000 - 86,000; Full time

Job summary

UConn Health in Farmington, CT is seeking a Clinical Documentation Specialist (RN) to ensure complete and compliant documentation across services. This full-time position collaborates with CDI physicians and coding staff to resolve discrepancies and support accurate DRG coding, reimbursements, and quality improvement.

The role requires a Connecticut RN license and 3+ years of acute care or utilization experience; strong written and verbal communication; and knowledge of ICD-10 coding.

Qualifications

• Active RN license in Connecticut.
• Three years' medical/surgical/critical care experience or three years utilization/clinical case management.
• Knowledge of ICD-10 CM coding and reimbursement principles.
• Strong written and verbal communication skills.
• Experience resolving coding/documentation discrepancies with CDI/Coding staff.

Responsibilities

• Oversee quality and completeness of clinical record documentation; train staff; monitor adherence to policies.
• Collaborate with CDI Physician Champion and Coding Manager to resolve DRG coding/docs discrepancies and training needs.

Skills

Regulatory guidelines

Documentation standards

Nursing process

Interpersonal skills

Oral & written communication

ICD-10 coding

Insurance reimbursement

Education

CT RN license

Tools

3M CDIS

Job description

(RN) Clinical Documentation Specialist, 2027-633

The University of Connecticut Health Center is an affirmative action employer, in addition to an EEO and M/F/V/PWD/PV employer.

All employees are subject to adherence to the State Code of Ethics which may be found at www.ethics.state.ct.us .

Our top rated organization is looking to add a full time Clinical Documentation Specialist in the Department Of Health Information Management at UConn Health located in Farmington, CT.

At the UCHC, this class is accountable for the quality of care reviews on all services in compliance with applicable standards and appropriate regulatory guidelines and/or ensuring that appropriate clinical documentation is captured for the level of services rendered to all patients.

SCHEDULE:

Full time, 40 hours per week, primarily Monday - Friday, 8:00 a.m. to 4:30 p.m. 30-minute unpaid meal break

MINIMUM QUALIFICATIONS REQUIRED

KNOWLEDGE, SKILLS AND ABILITY

Considerable knowledge of applicable regulatory guidelines; considerable knowledge of third party documentation standards and regulatory/legal guidelines; knowledge of quality assurance; knowledge of the nursing process; knowledge of insurance company reimbursement principles; knowledge of ICD-10 CM coding; knowledge of procedures applicable to various specialties; considerable interpersonal skills; considerable oral and written communication skills.

EXAMPLES OF DUTIES

• Oversees quality and completeness of clinical record documentation by all levels of staff; develops, maintains policies, procedures, protocols and other quality assurance and/or clinical documentation efforts; develops, conducts, coordinates training and education programs for staff; oversees the patient relations program; coordinates meetings as necessary; monitors documentation; identifies variances from practice and policy; attends meetings as required; supports institutional and departmental quality assurance activities; Works in collaboration with the CDI Physician Champion and Coding Manager to resolve DRG coding and documentation discrepancies, clinical disparities, and education/training needs for physicians, CDI and Coding staff; Participates in organizational and departmental initiatives and performance improvement projects; Maintains current knowledge of trends, regulations and technology related to documentation, coding, and reimbursements; performs related duties as required.

EXPERIENCE AND TRAINING

GENERAL EXPERIENCE

Registered Nurse and either three (3) years of medical/surgical/critical care experience in an acute care or clinical practice or three (3) years utilization/clinical case management experience in a hospital setting.

SPECIAL EXPERIENCE

Incumbents in this class must possess and maintain licensure as registered nurse in the State of Connecticut.

PREFERRED EXPERIENCE

Three (3) - five (5) years of experience in clinical documentation improvement/integrity.

Experience with 3M CDIS or other clinical documentation improvement software.

FULL TIME MINIMUM EQUIVALENT SALARY:

$77,875.00, more based on experience

WHY UCONN HEALTH

UConn Health is a vibrant, integrated academic medical center that is entering an era of unprecedented growth in all three areas of its mission: academics, research, and clinical care. A commitment to human health and well-being has been of utmost importance to UConn Health since the founding of the University of Connecticut schools of Medicine and Dental Medicine in 1961. Based on a strong foundation of groundbreaking research, first-rate education, and quality clinical care, we have expanded our medical missions over the decades. In just over 50 years, UConn Health has evolved to encompass more research endeavors, to provide more ways to access our superior care, and to innovate both practical medicine and our methods of educating the practitioners of tomorrow.