Clinical Documentation Integrity Specialist RN Job at UnityPoint Health
Overview:
*Must be within an hour of a UPH affiliate*
Summary
COVID-19 and Flu Vaccination Requirement: It is required to be fully vaccinated for COVID-19 and Influenza. Exemption requests based on medical or religious reasons may be submitted, but must be approved for active employment.
Visit us at UnityPoint.org/careers to hear more from our team members about why UnityPoint Health is a great place to work. https://dayinthelife.unitypoint.org/ Responsibilities:
Relationship Building/Collaboration
This position is open to remote/work from home with strong preference for candidates residing within the UPH geographies of Iowa, Illinois, & Wisconsin.
*Must be within an hour of a UPH affiliate*
Summary
The Clinical Documentation Specialist (CDS) is responsible for performing concurrent review of medical records to
ensure complete and accurate clinical documentation to support severity of illness, risk of mortality for outcomes
reporting, and for hospital reimbursement. The position requires a strong attention to detail and process orientation and
an ability to think globally about documentation requirements in the medical records.
COVID-19 and Flu Vaccination Requirement: It is required to be fully vaccinated for COVID-19 and Influenza. Exemption requests based on medical or religious reasons may be submitted, but must be approved for active employment.
Why UnityPoint Health?
- Commitment to our Team –We’ve been named aTop 150 Place to Work in Healthcare 2022 by Becker’s Healthcare for our commitment to our team members.
- Culture – At UnityPoint Health, you Come for a fulfilling career and experience a culture guided by uncompromising values and unwavering belief in doing what's right for the people we serve.
- Benefits – Our competitive Total Rewards program offers benefits options like 401K match, paid time off and education assistance that align with your needs and priorities, no matter what life stage you’re in.
- Diversity, Equity and Inclusion Commitment – We’re committed to ensuring you have a voice that is heard regardless of role, race, gender, religion, or sexual orientation.
- Development – We believe equipping you with support and development opportunities is an essential part of delivering a remarkable employment experience.
- Community Involvement – Be an essential part of our core purpose—to improve the health of the people and communities we serve.
Visit us at UnityPoint.org/careers to hear more from our team members about why UnityPoint Health is a great place to work. https://dayinthelife.unitypoint.org/
Operational
- Conducts reviews of designated medical records to facilitate the creation of a health record that accurately represents the acuity of the patient’s illness and the resources used to treat the patient by ensuring provider documentation supports all applicable diagnosis codes.
- Ensures assignment of the working DRG is supported by diagnostic and procedural findings from the medical record. This will include the identification of secondary diagnosis that may result in Complications and Co-morbidities (CC) and/or Major Complications and Co-morbidities (MCC) assignment.
Relationship Building/Collaboration
- Collaborates with coding staff and leaders for improved knowledge and understanding of coding guidelines.
- Collaborates with physicians and/or other hospital staff to coordinate work and resolve issues
- Collaborates with Clinical Documentation Integrity leaders to provide feedback and receive work direction
Education
- RN required
- BSN preferred
Experience
- Three (3) to five (5) years applicable acute care nursing experience
- Previous experience in clinical documentation improvement is preferred.
- Previous experience with chart review or chart auditing is preferred.
- Knowledge of ICD CM/PCS coding guideline is preferred.
Certifications/Licenses
- RN Licensure
- Valid Drivers License
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