RN-Clinical Documentation Specialist-Health Information **UnityPoint Health Finley Hospital** 1 Positions ID: 37638200 Posted On 09/19/2024 **Job Overview** **Overview** We're seeking a Clinical Documentation Integrity Specialist (CDIS) RN to join our team! In this role, you'll be responsible for performing concurrent review of medical records to ensure complete and accurate clinical documentation to support severity of illness, risk of mortality for outcomes reporting, and for hospital reimbursement. The position requires a strong attention to detail and process orientation and an ability to think globally about documentation requirements in the medical records. The CDS must communicate effectively in oral and written form to physicians and other clinicians to promote accurate and complete documentation during the patient’s course of care. CDS supports the hospital’s overall compliance efforts designed to ensure the accuracy of diagnosis and procedural coding, Diagnosis Related Group (DRG) assignment, severity of illness (SOI), and expected risk of mortality (ROM). **This position is remote/work from home and must be within 60 miles of a UnityPoint health affiliate in IL, IA, or WI.** **PLEASE NOTE: This position is subject to pre-hire testing.** **Why UnityPoint Health?** + **Commitment to our Team –** For the third consecutive year, we're proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare for our commitment to our team members. + **Culture –** At UnityPoint Health, **you** matter. Come for a fulfilling career and experience a culture guided by uncompromising values and unwavering belief in doing what's right for the people we serve. + **Benefits –** Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in. + **Diversity, Equity and Inclusion Commitment** – We’re committed to ensuring you have a voice that is heard regardless of role, race, gender, religion, or sexual orientation. + **Development** – We believe equipping you with support and development opportunities is an essential part of delivering a remarkable employment experience. + **Community Involvement** – Be an essential part of our core purpose—to improve the health of the people and communities we serve. Visit https://dayinthelife.unitypoint.org/ to hear more from our team members about why UnityPoint Health is a great place to work. **Responsibilities** **Medical Record Review and Documentation** + Responsible for concurrent and retrospective review of selected medical records to facilitate complete and accurate documentation of patient conditions, diagnoses, and procedures. + Performs and documents initial and concurrent reviews in software. + Identifies and accurately assigns coding existing conditions, complications and/or comorbid conditions. + Recognizes opportunities for documentation improvement and formulates clinically credible clarifications for the physician or provider. + Identifies issues promptly and appropriately per escalation process. **Relationship Building and Education** + Improve documentation by building relationships with and serving as a resource to physicians and hospital staff to promote open communication and education regarding complete and accurate documentation in the patient record. + Partner with other hospital departments in support of quality initiatives related to Clinical Documentation Improvement (e.g. Patient Safety Indicators, Quality Measures). **Qualifications** **Education:** + RN + BSN or higher preferred **Experience:** + At least 5 years of full-time adult acute care RN experience in med/surg, critical care, emergency or Utilization review. + Previous experience in clinical documentation improvement is preferred. + Previous experience with chart review or chart auditing is preferred. + Knowledge of ICD CM/PCS coding guidelines **License(s)/Certification(s):** + Registered Nurse licensure required + Certified Clinical Documentation Specialist (CCDS) preferred + Certified Documentation Improvement Practitioner (CDIP) preferred **Knowledge/Skills/Abilities:** + Excellent interpersonal and communication skills + Knowledge of reimbursement systems, federal, state, and payer specific regulations and policies pertaining to documentation and coding + Multicultural sensitivity + Microsoft Office – basic computer skills + Customer/patient focused + Critical thinking skills using independent judgment in making decisions + Action Planning + Ability to work independently + Highly motivated, self-starter who works effectively with minimum supervision + Ability to organize work quickly and efficiently and be comfortable working against deadlines + Maintain effective working relationships + **Area of Interest:** Nursing; + **FTE/Hours per pay period:** 1.0; + **Department:** Clinical Documentation; + **Shift:** Monday - Friday, days, for 80 hours per pay period.; + **Job ID:** 153809; Primary Contact 13511 Michelle Pickel HR Recruiter, HR 563-589-2608 Phone Phone Phone Fax michelle.pickel@unitypoint.org Email True False False **Job Details** Categories Health Care Location Dubuque, IA Job Type Employee Full/Part Full Time **Qualifications** Education Bachelors Company ID 168 Job REQ # 37638200 \# Positions 1 Start Date 20240919 End Date 20241214 Featured Job TH Ad TH Comments **Similar Jobs** Clinical Documentation Specialist (Evergreen) MercyOne Clinical Documentation Specialist MercyOne **Share this Job** UnityPoint Health Finley Hospital **About the Company** **A CAREER AT UNITYPOINT HEALTH - FINLEY HOSPITAL** UnityPoint Health team members come for a job, but stay for a career. As a team member, regardless of your position, you'll get the chance to change lives on a daily basis in order to deliver our vision of the Best Outcome for Every Patient, Every Time. That privilege drives employees' passion for making a difference in the lives of our patients, helping them create healthier, more rewarding lives. At UnityPoint Health - Finley Hospital, we know our collective actions determine the experience we create. Our team members strive to work as one through four key values: * Foster Unity * Own the Moment * Champion Excellence * Seize Opportunity If you are interested in joining our team, please visit http://www.unitypoint.org/dubuque/employment-opportunities to learn about our many opportunities and to fill out an online application. **ABOUT OUR HOSPITAL** UnityPoint Health Finley Hospital is a 126-bed community hospital. We employ more than 800 full-and-part-time employees. Finley Hospital is a not-for-profit, locally owned, regional healthcare facility part of the UnityPoint Health system. Finley Hospital is committed to bringing the best medical care to the tri-state area. We offer comprehensive, full service health care that is coordinated around our patients. We have consistently been recognized as a leader in health care.