RN-Clinical Documentation Specialist-Health Information

Job Overview

Overview

We're seeking a Clinical Documentation Integrity Specialist (CDIS) RN to join our team! In this role, you'll be responsible for performing concurrent review of medical records to ensure complete and accurate clinical documentation to support severity of illness, risk of mortality for outcomes reporting, and for hospital reimbursement. The position requires a strong attention to detail and process orientation and an ability to think globally about documentation requirements in the medical records. The CDS must communicate effectively in oral and written form to physicians and other clinicians to promote accurate and complete documentation during the patient’s course of care. CDS supports the hospital’s overall compliance efforts designed to ensure the accuracy of diagnosis and procedural coding, Diagnosis Related Group (DRG) assignment, severity of illness (SOI), and expected risk of mortality (ROM).

This position is remote/work from home and must be within 60 miles of a UnityPoint health affiliate in IL, IA, or WI.

PLEASE NOTE: This position is subject to pre-hire testing.

Why UnityPoint Health?

Commitment to our Team – For the third consecutive year, we're proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare for our commitment to our team members.
Culture – At UnityPoint Health, you matter. Come for a fulfilling career and experience a culture guided by uncompromising values and unwavering belief in doing what's right for the people we serve.
Benefits – Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in.
Diversity, Equity and Inclusion Commitment – We’re committed to ensuring you have a voice that is heard regardless of role, race, gender, religion, or sexual orientation.
Development – We believe equipping you with support and development opportunities is an essential part of delivering a remarkable employment experience.
Community Involvement – Be an essential part of our core purpose—to improve the health of the people and communities we serve.

Visit https://dayinthelife.unitypoint.org/ to hear more from our team members about why UnityPoint Health is a great place to work.

Responsibilities

Medical Record Review and Documentation

Responsible for concurrent and retrospective review of selected medical records to facilitate complete and accurate documentation of patient conditions, diagnoses, and procedures.
Performs and documents initial and concurrent reviews in software.
Identifies and accurately assigns coding existing conditions, complications and/or comorbid conditions.
Recognizes opportunities for documentation improvement and formulates clinically credible clarifications for the physician or provider.
Identifies issues promptly and appropriately per escalation process.

Relationship Building and Education

Improve documentation by building relationships with and serving as a resource to physicians and hospital staff to promote open communication and education regarding complete and accurate documentation in the patient record.
Partner with other hospital departments in support of quality initiatives related to Clinical Documentation Improvement (e.g. Patient Safety Indicators, Quality Measures).

Qualifications

Education:

RN
BSN or higher preferred

Experience:

At least 5 years of full-time adult acute care RN experience in med/surg, critical care, emergency or Utilization review.
Previous experience in clinical documentation improvement is preferred.
Previous experience with chart review or chart auditing is preferred.
Knowledge of ICD CM/PCS coding guidelines

License(s)/Certification(s):

Registered Nurse licensure required
Certified Clinical Documentation Specialist (CCDS) preferred
Certified Documentation Improvement Practitioner (CDIP) preferred

Knowledge/Skills/Abilities:

Excellent interpersonal and communication skills
Knowledge of reimbursement systems, federal, state, and payer specific regulations and policies pertaining to documentation and coding
Multicultural sensitivity
Microsoft Office – basic computer skills
Customer/patient focused
Critical thinking skills using independent judgment in making decisions
Action Planning
Ability to work independently
Highly motivated, self-starter who works effectively with minimum supervision
Ability to organize work quickly and efficiently and be comfortable working against deadlines
Maintain effective working relationships