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Summary Clinical Documentation Specialist RN
This is a full-time, non-exempt (hourly) position on UCHealth's CDI team based in Aurora, CO.
The Clinical Documentation Specialist RN is responsible for performing concurrent review of the clinical documentation in the written and electronic medical records in order to ensure compliant, appropriate and accurate reimbursement based on severity of patient illness, risk of mortality and level of services provided to patients.
Utilizing a collaborative approach with physicians, nursing staff, ancillary departments, and coding staff, ensures that clinical documentation is compliant, complete and accurate. The Clinical Documentation Specialist RN provides ongoing education and support to all members of the healthcare team in regard to clinical documentation in the medical record.
Analyzes documentation of the clinical status of patients, current treatment plan, and past medical history; identifies potential gaps in provider documentation.
Collaborates with physicians, case management, nursing, other patient care givers and coding staff to ensure medical record accurately reflects the clinical condition of patient.
Collaborates with coding staff to ensure documentation of diagnoses and pre-existing co-morbidities are a complete and accurately reflect the care received, as well as patient's clinical status, acuity, severity of illness, and risk of mortality.
Serves as a resource to providers to help link coding guidelines and medical terminology, to improve accuracy of the patient's severity of illness, risk of mortality, final code assignment and case mix index.
Associates Degree from an NLN or CCNE accredited nursing program with a minimum of 1 year of related clinical experience or Baccalaureate Degree in Nursing from an NLN or CCNE accredited baccalaureate nursing program with a minimum of 1 year of related clinical experience.
2 years of recent clinical experience in an acute inpatient nursing unit OR current work experience which requires frequent, appropriately assertive communication with physicians and other Licensed Independent Practitioners to clarify/discuss/recommend significant changes in patient's treatment/plan of care, and acute changes in patient condition, combined with at least 2 years of prior experience on a nursing care unit in an acute care facility.
Current Colorado RN license.
Current AHA certification in Basic Life Support (BLS). BLS through the American Heart Association or the American Red Cross CPR for the Professional Rescuer with card in-hand before start date. BLS or CPR card must be good through sixty days of hire. All life support certification cards must be issued by either the American Heart Association or the American Red Cross CPR for the Professional Rescuer. (American Red Cross for the Professional Rescuer is only good upon hire and all renewals will need to be through an American Heart Association sanctioned course.)
ICU and/or strong MED/SURG background with the ability to assess and identify acute and chronic relevant clinical conditions.
Certification in Specialty area.
CCDS or CDIP certification.
Going beyond quality requires the perfect balance of talent, integrity, drive and intellectual curiosity. We are looking for individuals who recognize, like us, that the world of medicine is ever-changing and are motivated to do what is right, not what is easy. We support creativity and curiosity so that each of us can find the extraordinary qualities within ourselves. At UCHealth, we'll do everything in our power to make sure you grow and have a meaningful career. There's no limits to your potential here.
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The University of Colorado Health (UCHealth) system recognizes and appreciates the rich array of talents and perspectives that equal employment and diversity can offer our institution. As an affirmative action/equal opportunity employer, UCHealth is committed to making all employment decisions based on valid requirements. No applicant shall be discriminated against in any terms, conditions or privileges of employment or otherwise be discriminated against because of the individual's race, creed, color, religion, gender, national origin or ancestry, age, mental or physical disability, sexual orientation, gender identity, transgender status, genetic information or veteran status. UCHealth does not discriminate against any "qualified applicant with a disability" as defined under the Americans with Disabilities Act and will make reasonable accommodations, when they do not impose an undue hardship on the organization.
With award-winning hospitals and facilities serving the entire Front Range, University of Colorado Health is the state’s largest and most innovative health system. By integrating the strengths of academic medicine with the finest community health care, we’re able to push the boundaries of medicine and offer our employees endless career opportunities. Here, there are no limits, except those you pla...ce on yourself. Everyone is united by their passion for discovery and their commitment to improving patients’ lives.