Clinical Documentation Improvement Nurse-Emergency Department

Clinical Documentation Improvement Nurse-Emergency Department

Requisition Number: 3967
Job Title: Clinical Documentation Improvement Nurse-Emergency Department
Department: UUH OPC 29A EMERGENCY RM
Reg / Temp: Regular
Employment Type: Full Time
Shift: Rotating
Work Schedule: varied
Location: UNIVERSITY HOSPITAL - 50 NORTH MEDICAL DRIVE
City: SALT LAKE CITY
State: UTAH

Job Description:
: As a patient-focused organization, the University of Utah Health Sciences 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. The Health Sciences Center seeks faculty and staff that are committed to the values of compassion, collaboration, innovation, responsibility, diversity, integrity, quality and trust that are integral to our mission.

Position Summary:
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.

Essential Functions:
- 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.

Knowledge / Skills / Abilities:
- Demonstrated potential ability to perform the essential functions as outlined above.
- 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:
Required
- Current license to practice as a Registered Nurse in the State of Utah
- Five years of clinical and critical nursing experience.
- Bachelor's degree in Nursing or equivalency.
- Basic Life Support Health Care Provider card or obtain one within one month of hire.

Preferred
- Knowledge of ICD-9 and DRG.