RN - Clinical Documentation Specialist II

Hello,

Thank you for your interest in career opportunities with the University of Mississippi Medical Center.  Please review the following instructions prior to submitting your job application:

• Provide all of your employment history, education, and licenses/certifications/registrations.  You will be unable to modify your application after you have submitted it.
• You must meet all of the job requirements at the time of submitting the application. 
• You can only apply one time to a job requisition. 
• Once you start the application process you cannot save your work. Please ensure you have all required attachment(s) available to complete your application before you begin the process.
• Applications must be submitted prior to the close of the recruitment. Once recruitment has closed, applications will no longer be accepted.

After you apply, we will review your qualifications and contact you if your application is among the most highly qualified. Due to the large volume of applications, we are unable to individually respond to all applicants. You may check the status of your application via your Candidate Profile.

Thank you,

Human Resources

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:

R00043107

Job Category:

Nursing

Organization:

Rev Cycle - HIM CDI

Location/s:

Jackson Medical Mall

Job Title:

RN - Clinical Documentation Specialist II

Job Summary:

To support and review the inpatient medical record in order 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

Five (5) years of clinical nursing in Acute Care, Utilization Review, Case Management, Quality Management and/or Hospital-based Clinical Documentation experience.   Hospital based Clinical Documentation experience preferred.

Certifications, licenses or registration required:

Valid RN license. CCDS (Certified Clinical Documentation Specialist) preferred upon hire, but is required within three years of hire.

Knowledge, Skills & Abilities

• Knowledge of evidence-based clinical guidelines across a wide variety of conditions and age groups. Knowledge of resource/utilization management. Skill in the use of personal computers and related software applications. Ability to manage multiple priorities under time constraints; ability to analyze and solve problems.
• Understanding of cost and quality issues. Excellent verbal and written communication skills.  Interpersonal skills to interact with a wide range of constituencies. Decision-making skills. 
• Demonstrated ability to perform and maintain working relationships within the department and across all business units to foster a team environment. Effective written and verbal communication skills required. Healthcare revenue cycle experience preferred. 
• Proficient knowledge and experience in Microsoft office Suite (Excel, PowerPoint, Word & Outlook).

• Responsibilities:

• Reviews inpatient medical record within 24-48 hours of admission to ensure accuracy and completeness and identifies documentation opportunities that reflect severity of illness, acuity, and resource consumption.  Assigns a working DRG based on principal diagnosis and procedure. Identifies comorbidities and complications. Identifies
• Present on admission diagnoses. Identifies quality issues and reports to the responsible party.  Is proficient in more complex decision-making with high degree of accuracy.
• Reviews and enters information in both epic and 3m 360 as required.  Proficient in using these software systems. 
• Ensures accuracy by reviewing inpatient charts every 24-48 hours as a follow-up. Identifies documentation that reflects the severity, acuity, quality issues and resource consumption and updates his/her findings in 3m 360 software.  Proficient in quality and production.