RN CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST

All the benefits and perks you need for you and your family :

Benefits from Day One for FT / PT positions

Paid Time Off from Day One for FT / PT positions

Student Loan Repayment Program for FT / PT positions

Career Development

Whole Person Wellbeing Resources

Mental Health Resources and Support

Paid Paternal Leave

Debt-free Education (Certifications and Degrees without out-of-pocket tuition expense)

Our promise to you :

Joining UChicago Medicine AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit.

UChicago Medicine AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ.

Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule : Full-time days

Location : Remote but must be available for in-person meetings every other month and in-person training / education as needed

The role you'll contribute :

Under general supervision of the Director of Clinical Documentation Integrity and in some situations the supervision of the Clinical Documentation Integrity Manager, and in collaboration with physicians, nursing and HIM coders, the Clinical Documentation Specialist (CDS) strategically facilitates and obtains appropriate and quality physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient.

The CDS educates members of the patient care team regarding documentation guidelines, including physicians, allied health practitioners, nursing, care management and etc.

The CDS adheres to strict departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality documentation and regulatory compliance.

Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

The value you'll bring to the team :

Demonstrates extending the healing ministry of Christ, through behavioral whole care standards of love me, make it easy, own it and keep me safe to every person they meet.

Delivers exceptional care and strives for excellence. Committed to improving the health, prosperity and well-being of the communities we serve.

Uphold the highest standards, with integrity driving every decision made and every action taken. Guided by relentless stewardship in the management of resources entrusted to them.

• Reviews concurrent medical record for compliance including completeness and accuracy for severity of illness (SOI), risk of mortality (ROM) and quality.
• Completes accurate and timely record review to ensure the integrity of documentation compliance. Completes accurate and concise input of data into CDI Software resulting in accurate metrics obtained through the reconciliation process.

Understands and supports CDI documentation strategies (upon completion of didactic training) and continues to educate self and team members, by attending monthly mandated education sessions and using educational tools, videos and provided Webinars

Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision making keeping quality considerations in balance with regulatory compliance.

Initiates / formulates CDI severity worksheets and clinically credible clarifications for inpatients, sending / presenting opportunities for improved documentation compliance to physicians, nurse practitioners and other clinical team members.

• Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs and HACs to ensure documentation compliance is accomplished.
• Strategically educates members of the patient-care team regarding documentation regulations and guidelines, including physicians, allied health practitioners, nursing, and collaboration with the healthcare team.

This includes quarterly and annual compliance updates from Medicare.

Effectively and appropriately communicates with physicians and other healthcare providers as necessary to ensure appropriate, accurate and complete clinical documentation.

Communicates with HIM staff and collaborates with them to resolves discrepancies with DRG assignments and other coding issues.

• Completes well-timed follow-up case reviews on all concurrent cases with priority given for resolution of those with clinical documentation clarifications.
• Participates in department meetings, including feedback on outstanding issues, presentations for educational opportunities and any other needs identified by the CDI leaders.

Assumes personal responsibility for professional growth, development and continuing education to maintain a high level of proficiency.

• Demonstrates competence in chart audits
• Correctly identifies physician clarification opportunities
• Proficient in formulating valid clarifications that are easily understood by physicians and other members of the medical team.
• Accurately reconciles all cases in CDI database.
• Maintains a 95% physician response rate to all valid clarifications.
• Performs other duties as assigned.

Qualifications

The expertise and experiences you'll need to succeed :

KNOWLEDGE AND SKILLS REQUIRED

• Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations.
• Able to organize and present information clearly and concisely; excellent computer and keyboarding skills; ability to use multiple software programs simultaneously;

high degree of prioritization skills.

• Ability to learn / develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist.
• Dependable, self-motivated and pleasant.
• Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills.
• Knowledge of pathophysiology, disease processes and treatments.
• Strong ability to organize / triage work and manage multiple priorities at once.

KNOWLEDGE AND SKILLS PREFERRED

• Knowledge of clinical documentation requirements that identify clinical conditions or procedures.
• Coding background.
• Knowledge of quality guidelines.

EDUCATION AND EXPERIENCE REQUIRED

• Minimum of five years acute care nursing experience with specific medical / surgical, Intensive Care, post-acute care unit, or Emergency Department experience.
• Minimum of one year of CDI experience

EDUCATION AND EXPERIENCE PREFERRED

• BSN or higher
• More than one year of Clinical Documentation Specialist experience

LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED

Current active State license as a Registered Nurse, Nurse Practitioner, Physician's Assistant or an unlicensed physician who has graduated from a medical school that is listed in the World Directory of Medical Schools ( World Directory ) as meeting eligibility requirements for its graduates to apply to the Educational Commission for Foreign Medical Graduates (ECFMG) for ECFMG Certification and examination at the time of graduation.

LICENSURE, CERTIFICATION OR REGISTRATION PREFERRED

• CCDS (Certified Clinical Documentation Specialist) certification
• CDIP (Certified Documentation Improvement Practitioner) certification

REQUIRED COMPETENCIES

• AdventHealth online learning (ALN)
• Achieve a 70% or greater on the AdventHealth Corporate Approved Pre-Hire Assessment
• Achieve a 70% or greater on the Annual AdventHealth Corporate Approved Post-Hire Assessment

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range.

The minimums and maximums for each position may vary based on geographical location.

Category : Nursing

Organization : UChicago Medicine AdventHealth Great Lakes

Schedule : Full-time

Shift : 1 - Day

Req ID : 24021374

We are an equal opportunity employer and do not tolerate discrimination based on race, color, creed, religion, national origin, sex, marital status, age or disability / handicap with respect to recruitment, selection, placement, promotion, wages, benefits and other terms and conditions of employment.