The Clinical Documentation Specialist II is responsible for improving overall quality and completeness of clinical documentation to ensure that the information in the medical record accurately reflects the patient's severity of illness, clinical needs, and utilization of resources.
Salary offered commensurate to experience
UAMS offers amazing benefits and perks:
Applies extensive clinical knowledge to read and analyze health record documentation, identifying all significant diagnoses, treatment, and procedures impacting acuity level and resources consumed throughout the current hospitalization; applies knowledge of disease processes, surgical procedures, UHDDS definitions, and the CMS/NCHS ICD-10 Official Coding Guidelines for Coding and Reporting to assign non-indexed terms to the appropriate class within the ICD-10 coding classification system.
Interacts directly with physicians, nursing staff, other patient caregivers, coding staff, and other members of the health care team to facilitate clarification of clinical documentation and transfer of knowledge related to accurate documentation, coding, and reimbursement practices; ensures that documentation is clear, concise, and written in diagnostic terms reflecting the highest level of specificity.
Develops and facilitates education related to clinical documentation improvement, coding guidelines, and regulatory requirements to all members of the healthcare team through one-on-one communication and classroom or large group presentations throughout the year as assigned.
RN plus 5 years inpatient clinical experience. Must have advanced clinical
expertise and extensive knowledge of complex disease processes with broad clinical
experience in an inpatient setting OR a Coding professional with CCS certification and
10 years of inpatient coding experience with documented education in anatomy/physiology and pharmacology
BSN or HIM degree, RHIA or RHIT, CCDS or CDIP preferred.