Clinical Documentation Specialist _ Part Time

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Important Applications Instructions:

Please complete this application in entirety by providing all of your work experience, education and certifications/ license.  You will be unable to edit/add/change your application once it is submitted.

Job Requisition ID:

R00054601

Job Category:

Nursing

Organization:

Rev Cycle - HIM CDI

Location/s:

Remote, UMMC Medical Tower

Job Title:

Clinical Documentation Specialist _ Part Time

Job Summary:

To support and review the inpatient medical record to facilitate improvement in overall quality, completeness, clinical severity, and accuracy of inpatient clinical documentation for DRG based or APR based payor population for specific departments or areas. To obtain and promote appropriate clinical documentation through extensive interaction with physicians and other members of the healthcare team.

Education & Experience

Education and Experience Required:

Two (2) years of nursing experience in Acute Care, Utilization Review, Case Management, and/or Quality Management.

Certifications, Licenses, or Registration required:

Valid RN license.

Preferred Qualifications:

• Prior nursing experience in the Emergency Department (ER), Intensive Care Unit (ICU), Medical-Surgical (Med-Surg), Trauma, or Surgical Services is preferred.
• Knowledge, Skills & Abilities
• Knowledge, Skills, and Abilities: Proficient knowledge of evidence-based clinical guidelines. General awareness of ICD-10 Inpatient Coding Guidelines preferred. Proficient knowledge of resource and utilization management and regulatory guidelines preferred. Excellent computer skills and proficiency with related software applications. Excellent verbal and written communication skills. Excellent analytical and problem-solving skills.

Responsibilities

• Reviews inpatient medical records within 24-48 hours of admission to ensure accuracy, completeness, and compliance, while identifying documentation opportunities that reflect severity of illness, acuity, and resource utilization
• Collaborates with physicians and other healthcare providers using clear, concise verbal and written communication to promote and support documentation improvement opportunities.
• Formulates basic, compliant queries (verbal or written) to clarify conflicting, ambiguous, or nonspecific documentation
• Identifies and evaluates clinical indicators to support accurate and appropriate patient diagnoses using strong clinical assessment skills.
• Applies current and emerging techniques to obtain, evaluate, and improve documentation related to patient care and record accuracy
• Determines when issues should be escalated to a Senior Clinical Documentation Specialist, provider, or administrator for resolution
• Collaborates with senior CDS staff to review complex or problematic cases and identify educational needs
• Maintains a strong understanding of risk management and quality indicators, including PSIs, HACs, and PPCs, and escalates relevant cases appropriately to senior team members
• The duties listed are general in nature and are examples of the duties and responsibilities performed and are not meant to be construed as exclusive or all-inclusive. Management retains the right to add or change duties at any time.
• Physical and Environmental Demands
• Requires no exposure to unpleasant or disagreeable physical environment such as high noise level and exposure to heat and cold, no handling or working with potentially dangerous equipment, occasional working hours beyond regularly scheduled  hours, occasional travelling to offsite locations, frequent activities subject to significant volume changes of a seasonal/clinical nature, constant work produced is subject to precise measures of quantity and quality, occasional bending, occasional lifting/carrying up to 10 pounds, occasional lifting/carrying up to 25 pounds, no lifting/carrying up to 50 pounds, no lifting/carrying up to 75 pounds, no lifting/carrying up to100 pounds, no lifting/carrying 100 pounds or more, occasional climbing, no crawling, occasional crouching/stooping, occasional driving, no kneeling, occasional pushing/pulling, frequent reaching, frequent sitting, frequent standing, occasional twisting, and frequent walking  (occasional-up to 20%, frequent-from 21% to 50%, constant-51% or more).
• Time Type: Part time
• FLSA Designation/Job Exempt: No
• Pay Class: Hourly
• FTE %: 47.5
• Work Shift: Day