Nurse Specialist, Clinical Documentation Improvement

Title: Nurse Specialist, Clinical Documentation Improvement

Location: UT-SALT LAKE CITY

Job Description:

Overview

As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, integrity, quality and trust that are integral to our mission. EO/AA

This position is responsible for improving the overall quality and completeness of clinical documentation by communicating with and providing education to physicians, case managers, coders and other health team members to facilitate comprehensive medical record documentation that reflects clinical treatment, decisions, and diagnoses for patients. This position may be required to access and administer medications within their scope of practice and according to state law.

Corporate 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.

• At the discretion of department operational and patient care needs, this position is required to work rotating schedules, which may include variable hours, weekends, nights, and holidays to meet the staffing and patient care demands of a 24/7 complex health system. Regular, reliable, and punctual attendance during assigned shifts is considered an essential function of the role.

Knowledge / Skills / Abilities

• Demonstrated ability to perform the essential functions as outlined above.

• Demonstrated availability to work variable and rotating shifts, including nights, weekends, and holidays, in a 24/7 patient care environment.

• 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.

* Additional license requirements as determined by the hiring department.

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

Listening, Sitting, Speaking

Multi-lingual Candidates Welcomed

To inquire about this posting, email: careers@hsc.utah.edu

EEO Statement

University of Utah Health Hospitals and Clinics, a part of The University of Utah, values candidates who have experience working in settings with students and patients from all backgrounds and possess a strong commitment to improving access to higher education and quality healthcare for historically underrepresented students and patient populations.

All qualified individuals are encouraged to apply. Veterans’ preference is extended to qualified applicants, upon request and consistent with University policy and Utah state law. Upon request, reasonable accommodations in the application process will be provided to individuals with disabilities.

University of Utah Health Hospitals and Clinics, a part of The University of Utah, is an Affirmative Action/Equal Opportunity employer and does not discriminate based upon race, ethnicity, color, religion, national origin, age, disability, sex, sexual orientation, gender, gender identity, gender expression, pregnancy, pregnancy-related conditions, genetic information, or protected veteran's status. The University does not discriminate on the basis of sex in the education program or activity that it operates, as required by Title IX and 34 CFR part 106. The requirement not to discriminate in education programs or activities extends to admission and employment. Inquiries about the application of Title IX and its regulations may be referred to the Title IX Coordinator, to the Department of Education, Office for Civil Rights, or both.

To request a reasonable accommodation for a disability, please contact the University of Utah Health Hospitals and Clinics Human Resources office at 801-581-6500. If you or someone you know has experienced discrimination or sexual misconduct including sexual harassment, you may contact the Director/Title IX Coordinator in the Office of Equal Opportunity (OEO). More information, including the Director/Title IX Coordinator's office address, electronic mail address, and telephone number can be located at: www.utah.edu/nondiscrimination/
Online reports may be submitted at oeo.utah.edu/

 

 

The University is a participating employer with Utah Retirement Systems (“URS”). Eligible new hires with prior URS service, may elect to enroll in URS if they make the election before they become eligible for retirement (usually the first day of work). Contact Hospitals and Clinics Human Resources at (801) 581-6500 for information. Individuals who previously retired and are receiving monthly retirement benefits from URS are subject to URS’ post-retirement rules and restrictions. Please contact Utah Retirement Systems at (801) 366-7770 or (800) 695-4877 or Hospitals and Clinics Human Resources at (801) 581-6500 if you have questions regarding the post-retirement rules.

This position may require the successful completion of a criminal background check and/or drug screen.

Requisition Number 80018
Reg/Temp Regular
Employment Type Full-Time
Shift Day
Work Schedule Monday-Friday 7:30am-4:00pm
Clinical/Non-Clinical Status Non-Clinical
Location Name Business Services Building
Workplace Set Up Remote
City SALT LAKE CITY
State UT
Department COR CST 17A HEALTH INFO CODING
Category Nursing
Workplace Set Up Remote