Clinical Documentation Specialist

Title: Clin Documentation Spec/UKHC

Location: Lexington, KY,  United States

Job Description:

Job TitleClin Documentation Spec/UKHC

Requisition NumberRE50235

Working TitleClinical Documentation Specialist

Department NameH4021: Revenue Management - Coding & Documentation

Work LocationLexington, KY

Grade Level11

Salary Range$54,080-95,056/year

Type of PositionStaff

Position Time StatusFull-Time

Required Education

ADN

Required Related Experience

7 yrs

Required License/Registration/Certification

Registered Nurse (RN)

Physical Requirements

The physical requirements of this position include: lifting, pushing, and/or pulling objects up to 10lbs; regularly walking or standing with objects up to 10lbs; regularly sitting at a computer workstation for extended periods of time with repetitive motions (such as typing); and occasional (<10% of the time) job-related travel.

Shift

Primarily days, Monday through Friday (8:00am-5:00pm). Some evenings, nights, and/or holidays may be required per departmental needs.

Job Summary

The Clinical Documentation Specialist will review physician documentation to identify the most appropriate DRG. When evidence supports additional diagnoses not documented in the proper format for final ICD-9 codes, the Clinical Documentation Specialist will clarify information with physician staff to ensure that diagnoses are appropriately documented in the medical record. This function is vital to capture the most accurate clinical picture of severity of illness, risk of mortality, co-morbidities, and complications. The Specialist will also assist in the capture of present-on-admission diagnoses. 

This is a primarily remote position with some on-site requirements.

Skills / Knowledge / Abilities

The ideal candidate will have the ability to manage multiple tasks and/or projects while accurately completing routine functions in a fast-paced, high intensity, professional work environment. This individual will also have knowledge of nursing theory; proficiency utilizing Microsoft Office applications; excellent attention to detail; exceptional planning and organizational skills, written and verbal communication skills, and time management and judgement abilities; the ability to solve routine problems and manage resources; and a demonstrated ability to provide superior customer service.

Does this position have supervisory responsibilities?No

Preferred Education/Experience

A Bachelor’s degree and at least five years of nursing experience are preferred.

Our University Community

We value the well-being of each of our employees and are dedicated to creating a healthy place for everyone to work, learn and live. In the interest of maintaining a safe and healthy environment for our students, employees, patients and visitors the University of Kentucky is a Tobacco & Drug Free campus.

As an Equal Opportunity Employer, we strongly encourage veterans, individuals with disabilities, women, and all minorities to consider our employment opportunities.

Any candidate offered a position may be required to pass pre-employment screenings as mandated by University of Kentucky Human Resources. These screenings may include a national background check and/or drug screen.