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Nurse Specialist-Clinical Documentation Improvement--South Jordan Health Center, PRN
2 months ago
Overview
: The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for our academic research, quality standards and overall patient experience. Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes. Responsibilities Ensures documentation meets quality standards and an accurate reflection of the patient's status is entered in the medical record. Provides education to staff and physicians on the importance of the Clinical Documentation Improvement Program (CDIP). Facilitates modifications to clinical documentation through extensive concurrent interactions with physicians, nursing staff and coding to support that appropriate reimbursement and clinical severity is captured. Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes. Assists the assigned coder with concurrently reviewing the medical records of inpatients and subsequently discusses documentation opportunities with the various physician teams. Acts as consultant to coders when additional information or documentation is needed to assign the correct DRG. Participates in assigned hospital, and unit and departmental committees.
Knowledge / Skills / Abilities
Demonstrated potential ability to perform the essential functions as outlined above. Ability to provide care to the population served. Demonstrated knowledge of the principles of life span growth and development and the ability to assess data regarding the patient's status and provide care as described in the department's policies and procedures manual. Demonstrated human relations and effective communication skills. Demonstrated ability to collaborate with coders, physician teams and hospital staff. Demonstrated knowledge of state and federal regulations. Ability to identify and monitor trends and opportunities for documentation improvement. Qualifications
Qualifications
Required
Five years of clinical and critical nursing experience. Bachelor's degree in Nursing or equivalency.
Licenses Required
Current license to practice as a Registered Nurse in the State of Utah, or obtain one within 90 days of hire under the interstate compact if switching residency to State of Utah. Must maintain current Interstate Compact (multi-state) license if residency is not being changed to Utah. Qualifications (Preferred)
Preferred
Knowledge of ICD-9 and DRG.
Working Conditions and Physical Demands
Employee must be able to meet the following requirements with or without an accommodation.
This is a sedentary position in an office setting that may exert up to 10 pounds and may lift, carry, push,pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions. Physical Requirements Color Determination, Far Vision, Listening, Manual Dexterity, Near Vision, Reaching, Sitting, Speaking, Standing, Stooping and Crouching, WalkingMulti-lingual Candidates Welcomed
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