Clinical Documentation Specialist
University of Iowa Health CareAbout the role
Description
The Clinical Documentation Improvement (CDI) program at UI Health Care has an opening for a full-time Clinical Documentation Specialist. The primary purpose of Clinical Documentation Improvement (CDI) is concurrent review of the medical record to increase the accuracy, clarity, and specificity of provider documentation (Association of Clinical Documentation Improvement Specialists, ACDIS).
Clinical Documentation Specialists bridge the gap between the providers and hospital coders to clarify at-risk documentation to ensure accurate claim submission (American Health Information Management Association, AHIMA). CDI chart reviews include:
Identifies and re-reviews high priority charts every two days or as needed
Retrospective reviews for query identification, documentation clarification, denials, or quality measures.
Completes quality reviews focused on CDI quality elements, such as Mortality, Hospital Acquired Conditions (HAC), and other publicly reported patient quality or safety metrics (i.e., AHRQ Patient Safety Indicators)
When provider documentation is illegible, incomplete, imprecise, inconsistent, conflicting, or unreliable the Clinical Documentation Specialist is expected to communicate (i.e., query) with the provider to obtain the necessary information to clarify the medical record (AHIMA, 2014).
The Clinical Documentation Specialist must hold a general proficiency within both the clinical and hospital coding skill sets. The Clinical Documentation Specialist provides the geometric mean length of stay (GMLOS) associated with the working DRG to identify the expected length of stay for acute inpatients.
The successful candidate will have:
A bachelor’s degree in nursing or a master’s degree in nursing (MNHP or MSN)
An Iowa nursing license
Three years of recent inpatient nursing experience in a medical-surgical, and/or ICU setting, and/or recent work experience as a Clinical Documentation Specialist, CDI nurse, or healthcare quality professional with specific medical record review experience
Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire.
Applicants must upload a current resume and a cover letter that clearly address how they meet the listed required and desired qualifications of this position.
Initial training and onboarding will take place at the Healthcare Support Services Building (HSSB), 3231 Ridgeway Drive, located in Coralville, IA 52241. This position is eligible to participate in 100% remote work after the initial training and onboarding has been completed. Remote work must be performed at a location within the state of Iowa and will require a work arrangement form to be completed upon the start of your employment. Per policy, work arrangements will be reviewed annually, and must comply with the remote work program and related policies and the employee travel policy when working at a remote location.
Job Duties and Responsibilities:
Establishes effective and collaborative relationships with members of the hospital community to improve accuracy and completeness of acute inpatient doc
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