Clinical Documentation Improvement Specialist; Cdis), On-Site

Responsibilities

When it comes to choosing a hospital, one thing is clear: quality and convenience count. Northern Nevada Medical Center's tradition of providing quality healthcare in a comfortable, accessible environment means peace of mind for the thousands of patients served by the hospital each year. Northern Nevada Medical Center is a 124-bed acute care hospital located on 23 hillside acres at 2375

E. Prater Way in Sparks, Nevada.

• Compassion
  :
  We treat everyone with kindness and warmth because we genuinely care about every patient, employee and physician like they are family.
• Empathy
  :
  We put ourselves in our patient’s shoes and deliver clinical care with a personalized touch.
• Teamwork
  :
  We foster a caring and friendly work environment to bring the best possible outcomes in our patient’s lives.
• Quality
  :
  We strive to provide excellence in clinical care.
• Ethics
  :
  We conduct our business with the highest ethical and moral standards.
• Respect
  :
  We promise to honor the dignity, individuality and rights of everyone.
• Service Excellence
  :
  We provide personalized and professional service that exceeds the expectations of those we serve.
• Innovation
  :
  We continually invest in technology and process improvements to develop new and better ways of delivering clinical care.

RELOCATION OFFERED

This CDIS, Clinical Documentation Improvement Specialist on-site only opportunity is full time @ 40 hours per week, offers full benefits and a convenient flexible schedule. This individual will provide clinically based concurrent and retrospective review of inpatient medical records to evaluate the utilization and documentation of acute care services. The goal of concurrent review includes facilitation of appropriate physician documentation of care delivered to accurately reflect patient severity of illness and risk of mortality.

Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care services.

• Conduct initial and extended-stay concurrent reviews on all selected admissions, and document findings within CDIS (electronic review system), denoting all key information (including working DRG and queries) utilized in the tracking process.
• Able to utilize inpatient admission criteria to assign only diagnoses that meet acute care criteria. In the event that diagnosis does not meet admission criteria, communicate with Case Management Department to determine the appropriate patient status.
• Collaborate with physician, physician extender, nurse, case manager/utilization review and HIM coder to identify principal diagnosis options, secondary diagnoses including complications and comorbidities, and procedures, to assign working DRGs for at least 80%-85% of the identified populations.
• Identify need to clarify documentation in medical records, and utilize strong communication skills with physician, physician extender, case manager, utilization review, nurse or other healthcare professional, utilizing appropriate tools to capture needed documentation.
• Utilize monitoring tools to track the progress of the DRG Assurance program, through interpretation of the CDIS tracking reports, monitoring reports and data. Able to identify areas of focus through report analysis. Serve as a resource to physicians and Administration regarding issues related to the appropriateness of inpatient DRG assignment.

• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• Tuition Reimbursement/Repayment Program
• Career development opportunities within UHS and its 300+ Subsidiaries!
• More information is available on our Benefits Guest Website:

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again…