Clinical Nursing Consultant II - Clinical Documentation Improvement Specialist

Clinical Nursing Consultant II - Clinical Documentation Improvement Specialist

Hiring Department: Clinical Documentation Improvement Specialist

Location: Chicago, IL USA

Requisition ID: 1025121

FTE : 1.0

Work Schedule - 08:00 AM- 4:30 PM

Shift : Days

of Position:

3

Posting Date: 05/10/2024

This position requires Illinois residency within 180 days of the hire date.

About the University of Illinois Chicago

UIC is among the nation's preeminent urban public research universities, a Carnegie RU/VH research institution, and the largest university in Chicago. UIC serves over 34,000 students, comprising one of the most diverse student bodies in the nation and is designated as a Minority Serving Institution (MSI), an Asian American and Native American Pacific Islander Serving Institution (AANAPSI) and a Hispanic Serving Institution (HSI). Through its 16 colleges, UIC produces nationally and internationally recognized multidisciplinary academic programs in concert with civic, corporate and community partners worldwide, including a full complement of health sciences colleges.

By emphasizing cutting-edge and transformational research along with a commitment to the success of all students, UIC embodies the dynamic, vibrant and engaged urban university. Recent "Best Colleges" rankings published by U.S. News & World Report, found UIC climbed up in its rankings among top public schools in the nation and among all national universities. UIC has nearly 260,000 alumni, and is one of the largest employers in the city of Chicago.

Description:

Position Summary The Clinical Documentation Specialist facilitates the improvement in the overall quality, completeness, and accuracy of clinical documentation in the medical record. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, and Health Information Management coding staff.

Ensures that the clinical severity and risk of mortality for the level of services provided are appropriately documented for inpatient accounts. Educates members of the patient care team on documentation guidelines on an ongoing basis.

Duties & Responsibilities

Essential Responsibilities

Clinical Documentation Improvement/Quality/Education

Facilitates appropriate clinical documentation to ensure that the level of services and acuity of illness are accurately reflected in the medical record.

Improves overall quality and completeness of clinical documentation for identified patient populations.

Demonstrates knowledge of MS-DRG and APR-DRG payer issues, documentation opportunities, clinical documentation requirements, coding, policies and procedures, and quality measures.

Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines for selected patient populations.

Formulates compliant and credible clinical documentation clarifications or queries to improve clinical documentation of principal diagnosis, co-morbidities, clinical severity and risk of mortality, present on admission (POA), quality core measures, and patient safety indicators (PSI).

Updates worksheet to reflect any changes in patient status, procedures/treatments, and confers with the physician to finalize diagnoses as required.

Conducts timely follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been recorded in the patient's chart.

Collaborates with the coding staff concurrently and retrospectively and reviews clinical issues as needed with the Coding Staff for the accuracy of coding.

Responsible for accurate, timely entry of pertinent data.

Assumes the responsibility for achieving program objectives.

Maintains positive communication with physicians, CDI team members, and management.

Assists in special projects as required.

Collaborates with other nurses and physicians to identify, promote, and provide positive learning experiences for providers.

Provides CDI education to nursing staff, and Allied Health Professionals as appropriate.

Initiates one-on-one physician education interaction as indicated for clarification and documentation needs.

Assists in the development of educational presentations to medical providers for awareness of documentation requirements.

Provides clinical information and education to coding staff as needed.

Assists Clinical Documentation Improvement Director in providing education to Physician Liaisons regarding medical payment systems, coding rules, and healthcare reporting.

Professional/Leadership

Participates in organizational, departmental, and shared leadership activities; supports department goals in daily behavior.

Demonstrates accountability for job performance by (1) seeking opportunities to enhance job skills and knowledge; and (2) maintaining conditions of employment (RN licensure, CCDS, and other required certifications).

Demonstrates a broad scope of clinical expertise.

Demonstrates effective time management skills.

As needed, recommends quality and/or performance improvement initiatives to more effectively and efficiently perform job functions.

Accesses Medical Center intranet for relevant communication and to review and interpret changes in policy, procedure, and other information pertinent to the role.

Takes responsibility for continued professional growth/development by identifying learning needs and initiating strategies to meet such needs.

Stays current with ongoing clinical documentation education.

Maintains professional growth by participating in conferences, professional development courses, etc.

Performs other job functions related to this job, as assigned.

Organizational

Adheres to the UI Health's Code of Conduct.

Treats patients/families, staff, students, and visitors with respect and dignity.

Adheres to Nursing's time, overtime, and attendance policies.

Completes electronic learning modules and related programs as assigned by UI Health by established date.

Complies with University Health Services TB and fit-testing requirements.

Utilizes established communication channels/chain of command to escalate or resolve patient care problems.

Identifies recurring clinical practice and/or related unit problems and participates in problem-solving and resolution.

Reporting Structure

This person works independently within the scope of the Clinical Documentation Improvement Program. The CDI Director, acting as coach and mentor, provides direction, guidance, and feedback regarding practice and performance.

The employee's performance is evaluated annually in writing and more frequently if needed. The employee and the Director meet on an as-needed basis for coaching and mentoring where support, guidance, and direction can be given.

Qualifications:

Minimum Qualifications

Required

Current license as a Professional Registered Nurse from the State of Illinois

Bachelor's Degree in Nursing (BSN)

Minimum of 3 years of acute care bedside nursing experience

Minimum of 3 years of Clinical Documentation Improvement experience in the acute care setting

Strong interpersonal and effective communication skills (oral and written), conflict management, and negotiation skills.

Analytical skills necessary to independently collect, analyze, and interpret clinical data.

Intermediate computer skills and willingness to learn computer applications relative to this position.

Preferred Qualifications

Preferred

Five years of experience in medical/surgical, critical care, intensive care, or emergency care

Extensive knowledge and experience in ICD-10 coding classification and DRG system and Quality Measures.

CCDS certification

Master's Degree

The University of Illinois System is an equal opportunity employer, including but not limited to disability and/or veteran status, and complies with all applicable state and federal employment mandates. Please visit Required Employment Notices and Posters to view our non-discrimination statement and find additional information about required background checks, sexual harassment/misconduct disclosures, and employment eligibility review through E-Verify.

The university provides accommodations to applicants and employees. Request an Accommodation