Documentation Specialist | 40 hours per week | Clinical Documentation

Minimum Hiring Wage:

From $81,889.60 a year

Job Details:

Scheduled hours: M-F, day shift

Job Description:

A Brief Overview

CDI are responsible for improving overall quality and completeness of clinical documentation by inpatient providers. CDI facilitates modifications to documentation through extensive interaction with physicians and clinical staff to ensure appropriateness of documentation. CDI ensures accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes. CDI staff also coordinate with coding team to ensure most accurate representation of the patient's illness and treatment. Educates all members of the patient care team on an ongoing basis regarding clinical documentation.

What you will do

• Clinical documentation review of documentation-Accurate and timely record review.-Recognize opportunities for documentation improvement.-Formulate clinically credible clarifications.-Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impact this knowledge to physicians and other members of the healthcare team. Gather and analyze information pertinent to documentation findings and outcomes. -Review problem list and query providers to provide a more accurate picture of the patient's health history.
• Excellent communication skills-Effective and appropriate communication with physicians-Timely follow up on all cases especially those with clarifications.-Communicates with HIM and Coding staff and resolves discrepancies-Communication with providers face to face or via clinical documentation inquiries regarding missing, unclear or conflicting medical record documentation to clarify the information.
• Excellent organization skills-Manage multiple priorities-Regular and reliable attendance.
• Appeal denied claims and follow up on the appeal status.
• Problem solves issues with computers and software

Qualifications

• Graduate of nursing program Required
• Bachelor’s degree in arts/sciences (BA/BS) Bachelor of Science of Nursing Preferred
• 4-6 years Nursing experience in an acute care setting Required
• 1-3 years CDI experience Preferred
• Clinical and computer skills and training are required
• Proficiency with Microsoft Office preferred
• Project implementation and management skills are preferred
• Keyboarding skills are preferred
• Educator, communication and problem-solving skills
• Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
• Knowledge of human behavior and performance; individual differences in ability, personality, and interests; learning and motivation; psychological research methods; and the assessment and treatment of behavioral and affective disorders.
• Understanding written sentences and paragraphs in work related documents.
• Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
• Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.
• Selecting and using training/instructional methods and procedures appropriate for the situation when learning or teaching new things.
• Teaching others how to do something.
• The ability to combine pieces of information to form general rules or conclusions (includes finding a relationship among seemingly unrelated events).
• The ability to listen to and understand information and ideas presented through spoken words and sentences.
• The ability to communicate information and ideas in speaking so others will understand.
• The ability to speak clearly so others can understand you.
• The ability to identify and understand the speech of another person.
• Registered Nurse Required

Qualifications:

This position is onsite in West Burlington, Iowa.

Benefits:

We are excited to offer an aggressive compensation and benefits package for qualifying positions, which includes:

• Competitive base pay

• Matching retirement programs

• Health, Dental and Vision plans

• Health Savings and Flexible Spending Accounts

• Employee discounts including car rental, cell-phone plans

• Employer-paid, Long-Term Disability, Life, and AD&D

• Paid time off (PTO)

• Education