Clinical Documentation Specialist

Description

Clinical Documentation Specialist

Location:

UCHealth Leprino Building AMC, Aurora CO

Department:
Clinical Documentation Integrity

Work Schedule:

Full Time, 80.00 hours per pay period (2 weeks)

Shift: Days

Pay: $37.06 - $57.44 / hour. Pay is dependent on applicant's relevant experience

This position is 100% remote. Qualified, eligible out-of-state candidates may be considered.

Summary:

Performs concurrent review of clinical documentation in written and electronic medical records to ensure compliant, appropriate and accurate reimbursement based on severity of patient illness, risk of mortality and level of services provided to patients. Collaborates with physicians, nursing staff, ancillary departments, and coding staff to ensure clinical documentation is compliant, complete and accurate. Provides ongoing education and support to the healthcare team in regard to clinical documentation in the medical record.

Responsibilities:

Reviews inpatient medical records for areas of opportunity regarding clinical documentation of diagnosis and procedures to assign a working DRG for identified population. Conducts reviews and documents findings.

Identifies need to clarify documentation in records; communicates with providers to capture documentation that supports the severity of illness and risk of mortality. Conducts follow up reviews for responses to physician queries. Serves as a resource to physicians and staff.

Works with coding staff to assure documentation of diagnoses and comorbidities or complications are a complete reflection of the patient's clinical status and care.

Maintains knowledge of requirements and guidelines to include changes/updates to practice or requirements.

Within scope of job, requires critical thinking skills, decisive judgement and the ability to work with minimal supervision. Must be able to work in a fast-paced environment and take appropriate action.

Requirements:

• Graduate of an accredited or state board of nursing approved Registered/Professional Nursing program. Associate or Bachelor of Science in Nursing (RN / BSN) or Nurse Practitioner (NP) or Physician Assistant (PA), or a medical degree (MD/DO). US-accredited international medical programs are accepted.

• State licensure as a Registered Nurse (RN) or Nurse Practitioner (NP) and Registered Nurse (RN) or Physician Assistant (PA). No active licensure is required for MD/DO.

• 5 years of recent clinical experience in an acute inpatient setting OR 1-year recent CDI experience. Preferred:
  Critical care and MED/SURG background with the ability to assess and identify relevant acute and chronic medical conditions. CDI experience.

Employees are our number one asset.

UCHealth promotes a culture that invests in professional success and personal well-being through a comprehensive total rewards program. *

• Performance bonus: UCHealth offers a 3-Year Incentive Bonus to recognize employee contributions to our success in quality, patient experience, organizational growth, financial goals and tenure. The bonus accumulates annually each October and is paid out in October during the third year of employment.

• Performance-based pay increase:
  The Annual Merit Pay Increase recognizes work performance that meets or consistently exceeds performance standards documented through UCHealth's established evaluation process and accounts for increased experience, skills and cost of living.

• Market reviews:
  All UCHealth positions are reviewed annually to ensure UCHealth base pay aligns with market standards. Base pay rates are adjusted as needed to stay market competitive.

• Medical, dental and vision coverage.

• Access to 24/7 mental health and well-being support for employees and dependents.

• Discounted gym memberships and fitness…