Clinical Doc Specialist RN 2-24370

Location: Chicago, Illinois

Business Unit

Hospital: Rush University Medical Center

Department: CM- CDI

Work Type: Full Time (Total FTE between 0.9 and 1.0)

Shift: Shift 1

Work Schedule: 8 Hr (7:00:00 AM - 3:30:00 PM)

Rush offers exceptional rewards and benefits learn more at our Rush benefits page (https://www.rush.edu/rush-careers/employee-benefits).

Pay Range: $46.06 - $74.32 per hour

Rush salaries are determined by many factors including, but not limited to, education, job-related experience and skills, as well as internal equity and industry specific market data. The pay range for each role reflects Rush’s anticipated wage or salary reasonably expected to be offered for the position. Offers may vary depending on the circumstances of each case.

Summary

The Clinical Documentation Specialist II (CDS II) demonstrates expert knowledge of documentation principles and is responsible for improving the overall quality and completeness of clinical documentation. The CDS facilitates modifications to clinical documentation through intensive interaction with providers (physicians/APPs), nursing staff, other patient care givers, and Health Information Management (HIM) coding staff to ensure that documentation accurately reflects each patient’s severity of illness and risk of mortality. Participates in the monitoring of quality indicators. In addition, the CDS II ensures accuracy and completeness of clinical information used for measuring and reporting physician and Rush outcomes, and educates all members of the patient care team on an ongoing basis. Exemplifies the Rush mission, vision and values and acts in accordance with Rush policies and procedures.

Other Information

Required Job Qualifications:

• State licensed RN and BSN.
• 5 years inpatient coding or clinical nursing experience with medical/surgical care management expertise.
• 2 years of clinical documentation improvement audit experience
• Certification in clinical documentation improvement
• Demonstrated critical thinking skills.
• Demonstrates expert knowledge of DRG payer issues, documentation requirements and strategies, as well as policies and procedures.
• Coding knowledge and/or clinical documentation improvement program experience is required.
• Advanced knowledge of inpatient ICD-10-CM and PCS guidelines.
• Knowledge of medical terminology, classifications systems and vocabularies.
• Knowledge of privacy and security regulations, confidentiality, and access and release of information practices.
• Excellent interpersonal communication skills, ability to work independently and collaboratively with all members of the health care team.
• Computer skills and the willingness to learn CDI software is required
  
  

Disclaimer: The above is intended to describe the general content of and requirements for the performance of this job. It is not to be construed as an exhaustive statement of duties, responsibilities or requirements.

Responsibilities

• Improves the overall quality and completeness of clinical documentation by independently performing initial and continued stay reviews using Rush clinical documentation guidelines.
• Queries and facilitates modifications to clinical documentation to ensure that documentation accurately reflects each patient’s severity of illness and risk of mortality.
• Participates in the monitoring of quality indicators.
• Conducts timely reviews of clinical documents in highly complex cases, evaluating quality measures, consistency, completeness of documents, and accuracy for severity of illness (SOI) and risk of mortality (ROM).
• Provides ongoing communication with coders, auditors, care managers, nurses, and providers to assure that documentation reflects the care and services provided.
• Documents actions in the CDI software (3M 360, Epic CDI, and Iodine) including queries and responses.
• Processes discharges by updating the appropriate CDI software to reflect any changes in status, procedures/treatments, and conferring with physicians to finalize diagnoses.
• Assists HIM in resolving post discharge queries.
• Provides expert clinical expertise, based on specific criteria and/or age specific considerations, as follows: (age appropriate communication skills, safety needs, therapeutic pharmacology, growth and development, psychosocial, assessment and interpretation of age specific data, and diagnosis)
• Providers to ensure quality and continuity of patient care.
• Educates internal customers on clinical documentation opportunities, coding and reimbursement issues, as well as performance improvement methodologies.
• Develops and conducts ongoing clinical documentation improvement education for new staff, including new CDS, care managers, coders, physicians, residents, nursing and allied health professionals.
• Reviews complex clinical issues with the coding staff to assign a working DRG, identifies educational opportunities, and seeks guidance as needed.
• Analyzes inpatient records for appropriateness and compliance with all federal, state, and other regulatory requirements.
• Maintains current knowledge of all issues related to coding, diagnosis, treatment, and reimbursement.
• Serves as an expert resource to all levels of clinical staff and participates in the development of curriculum for in-service trainings and education of professional staff to achieve improved results in clinical documentation and appropriate reimbursement.
• Participates in tracking responses to clinical documentation improvement efforts and trends in compliance. Suggests strategies to address trends.
• Maintains a customer service focus.
• Serves on CDI Task Force and supports project related activities
• Assists in special projects as needed.
  
  

Rush is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics.