Job Description

Clinical Documentation Specialist RN at UCHealth summary: A Clinical Documentation Specialist RN reviews and analyzes clinical documentation in medical records to ensure accurate, compliant, and complete coding related to patient diagnoses and treatments. They collaborate with physicians, nursing, and coding staff to clarify and enhance documentation, supporting appropriate reimbursement and reflecting patient severity and risk. The role involves education, follow-up on documentation queries, and maintaining knowledge of regulatory requirements in a fast-paced healthcare environment. Description Clinical Documentation Specialist RN Location: UCHealth Leprino Building AMC, US:CO: Aurora Department: Clinical Documentation Integrity FTE: Full Time, 1.0, 80.00 hours per pay period (2 weeks) Shift: Days Pay: $37.06 - $57.44 / hour. Pay is dependent on applicant's relevant experience Summary: Performs concurrent review of clinical documentation in written and electronic medical records to ensure compliant, appropriate and accurate reimbursement based on severity of patient illness, risk of mortality and level of services provided to patients. Collaborates with physicians, nursing staff, ancillary departments, and coding staff to ensure clinical documentation is compliant, complete and accurate. Provides ongoing education and support to the healthcare team in regard to clinical documentation in the medical record. This is a remote opportunity; eligible out-of-state candidates may be considered. Responsibilities: Reviews inpatient medical records for areas of opportunity regarding clinical documentation of diagnosis and procedures to assign a working DRG for identified population. Conducts reviews and documents findings. Identifies need to clarify documentation in records; communicates with providers to capture documentation that supports the severity of illness and risk of mortality. Conducts follow up reviews for responses to physician queries. Serves as a resource to physicians and staff. Works with coding staff to assure documentation of diagnoses and comorbidities or complications are a complete reflection of the patient's clinical status and care. Maintains knowledge of requirements and guidelines to include changes/updates to practice or requirements. Within scope of job, requires critical thinking skills, decisive judgement and the ability to work with minimal supervision. Must be able to work in a fast-paced environment and take appropriate action. Requirements: • Graduate of an accredited or state board of nursing approved Registered/Professional Nursing program. • CO State licensure as a Registered Nurse (RN). • 5 years of recent clinical experience in an acute inpatient nursing unit OR current work experience that requires communication with providers, with 5 years of nursing in an acute care facility. Preferred: • Critical care and MED/SURG background with the ability to assess and identify relevant acute and chronic medical conditions. • CDI experience. We improve lives. In big ways through learning, healing, and discovery. In small, personal ways through human connection. But in all ways, we improve lives. UCHealth invests in its Workforce. UCHealth offers a Three Year Incentive Bonus to recognize employee's contributions to our success in quality, patient experience, organizational growth, financial goals, and tenure with UCHealth. The bonus accumulates annually each October and is paid out in October following completion of three years' employment. UCHealth offers their employees a competitive and comprehensive total rewards package (benefit eligibility is based off of FTE status): • Medical, dental and vision coverage including coverage for eligible dependents • 403(b) with employer matching contributions • Time away from work: paid time off (PTO), paid family and medical leave (inclusive of Colorado FAMLI), leaves of absence; start your employment at UCHealth with PTO in your bank • Employer-paid basic life and accidental death and dismemberment coverage with buy-up coverage options • Employer paid short term disability and long-term disability with buy-up coverage options • Wellness benefits • Full suite of voluntary benefits such as flexible spending accounts for health care and dependent care, health savings accounts (available with HD/HSA medical plan only), identity theft protection, pet insurance, and employee discount programs • Education benefits for employees, including the opportunity to be eligible for 100% of tuition, books and fees paid for by UCHealth for specific educational degrees. Other programs may qualify for up to $5,250 pre-paid by UCHealth or in the form of tuition reimbursement each calendar year Loan Repayment: • UCHealth is a qualifying employer for the federal Public Service Loan Forgiveness (PSLF) program! UCHealth provides employees with free assistance navigating the PSLF program to submit their federal student loans for forgiveness through Savi. UCHealth always welcomes talent. This position will be open for a minimum of three days and until a top applicant is identified. UCHealth recognizes and appreciates the rich array of talents and perspectives that equal employment and diversity can offer our institution. As an 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, color, national origin, language, culture, ethnicity, age, religion, sex, disability, sexual orientation, gender, veteran status, socioeconomic status, or any other characteristic prohibited by federal, state, or local law. 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. Who We Are (uchealth.org)

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