Clinical Documentation Specialist, Outpatient
1 week ago
Be a part of a world-class academic healthcare system, The University of Chicago Medicine, as a Clinical Documentation Specialist at our Center for Transformative Care department. This is a remote, work from home opportunity and you may be based outside of the greater Chicagoland area.
Eligible for Sign-On Bonus up to $1,500
Job Summary:The Clinical Documentation Specialist (CDS) is responsible for facilitating improvement in the overall quality and completeness of medical record documentation on a concurrent basis. The CDS promotes modifications to medical record documentation to ensure accurate depiction of the level of clinical services provided to the patient and to completely describe patients severity of illness.
Key Responsibilities:- Reviews and re-reviews inpatient medical records for identified payer populations (primarily DRG/Case Rate payment methodology) beginning approximately 48 hours after admission.
- Communicates with attending physician(s) verbally and through written methodology to validate observations, and obtain clarification of incomplete, unclear, and ambiguous documentation including clarification of POA.
- Demonstrates and applies basic knowledge of documentation requirements and guidelines in accordance with ICD-9 CM Official Guidelines for Coding and Reporting.
- Works closely with HIM coding staff to assure documentation of principal diagnosis and any co-existing comorbidities and complications accurately reflect the patients clinical status and level of services provided.
- Consistently meets established productivity targets for record review.
- Develops and implements plans for both formal and informal education of physician, nursing and other clinical staff.
- Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
- Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management.
- Performs other duties as requested by senior management.
- 5 -8 years progressive work experience: Case Management or Med/Surg or Critical Care Nursing experience preferred.
- Basic computer skills in word processing and spreadsheet utilization.
- Excellent interpersonal skills necessary to develop and foster effective physician communication.
- Analytic skills necessary to clinically assess medical records.
- Excellent prioritization and organizational skills.
- Must be an actively licensed Registered Nurse in the state of Illinois.
- A Bachelor's degree in Nursing.
- Master's degree in Nursing.
- CCS coding credential.
We've been at the forefront of medicine since 1899. We provide superior healthcare with compassion, always mindful that each patient is a person, an individual. To accomplish this, we need employees with passion, talent and commitment with patients and with each other. We're in this together: working to advance medical innovation, serve the health needs of the community, and move our collective knowledge forward. If you'd like to add enriching human life to your profile, The University of Chicago Medicine is for you. Here at the forefront, we're doing work that really matters. Join us. Bring your passion.
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