University of Arkansas for Medical Sciences

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Clinical Documentation Specialist II

Clinical Documentation Specialist II

Requisition ID 
2017-40668
Category 
Nursing - Admin/Education
Position Type 
Regular Full-Time
Sub Category 
..
Department 
ICE CORE HIM Hospital Coding B
Posted Date 
1/12/2018
Post End Date 
1/26/2018

More information about this job

Overview

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:

  • Retirement: 5% retirement contribution from UAMS when an employee contributes at least 2%. Up to 10% matched contribution.
  • Education: 50% discount for staff (undergraduate); 50% discount for spouse and dependents (undergraduate only) when they attend UAMS and 40% discount at any other campus.
  • Health: Medical, Dental and Vision plans available for staff and family.
  • UAMS provides Basic Life Insurance up to $50,000.
  • Leave Time: 11 paid holidays annually, 22.5 days of annual vacation leave, 12 days of sick leave.
  • Merchant discounts
  • Training and education opportunities.

Responsibilities

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.

Qualifications

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.

 

Physical Requirements

Stand: Occasionally
Sit: Continuously
Walk: Occasionally
Bend, crawl, crouch, kneel, stoop, or reach overhead: Occasionally
Lift, push, pull, carry weight: 10 lbs or less
Use hands to touch, handle, or feel: Continuously
Talk: Frequently
Hear: Frequently
Taste or smell: Never
Read, concentrate, think analytically: Continuously
Physical Environment: Inside Medical Facility Environment, Inside Office Environment
Noise Level: Moderate
Visual Requirements: Near visual acuity
Hazards: None