Clinical Document Specialist (RN), Corporate Coding Services, Full Time, First Shift

About the role

UC Health is hiring a Full Time Clinical Documentation Improvement Specialist for Corporate Coding Services.

Responsibilities

• Conducts concurrent review of inpatient medical records on assigned units to ensure that the acuity of care and specificity of diagnoses are accurately reflected in the medical record.
• Completes Documentation Clarification communication tool when physician needs to be queried around clinical documentation issues.
• Conducts follow-up review to ensure physician review and response to these clarification requests.
• Works with department Director and hospital Medical Directors to escalate identified medical staff documentation issues, trends and medical staff compliance issues as needed.
• Acts as adhoc coverage for CDI staff at other UC Health hospitals, as needed.
• Provides ongoing educational updates to physicians on documentation and revenue cycle rules and regulations.
• Enters information into appropriate databases as required to be used for statistical and performance improvement reporting purposes.
• Works with hospital HIM Coding staff to ensure documentation clarifications have been reviewed and coded appropriately as part of the revenue cycle process.
• Assists with the orientation, coaching and mentoring of new CDI associates, as needed.
• Stays abreast of clinical documentation improvement resources to facilitate process efficiencies and educational needs.

Qualifications

• Registered Nurse from an accredited school of Nursing, College or University required.
• Bachelor of Science in Nursing (BSN) preferred, but not required.
• Current RN License in Ohio
• At least two years CDI experience preferred. Will accept at least three years acute inpatient med/surg experience, case management/UR experience, or clinical auditor experience.