Senior Clinical Documentation Specialist (RN required)

Discover Vanderbilt University Medical Center:  Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of diverse individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and where your diversity of culture, thinking, learning, and leading is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt’s mission is to advance health and wellness through preeminent programs in patient care, education, and research.

Organization:

HIM - CDE - 2

Job Summary:

JOB SUMMARY
Ensures capture of discharge diagnosis and procedures independently. Documents the patient's clinical status and care provided. Performs concurrent review of patient records for documentation to support assignment of clinical codes.

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KEY RESPONSIBILITIES
• Performs assessment of patient records to evaluate documentation for accuracy, legibility and completeness.
• Works with coding staff to ensure documentation of discharge diagnoses, including any coexisting co-morbidities, and procedures are complete.
• Communicates with providers regarding missing, unclear, or conflicting clinical documentation.
• Collaborates with case managers, nursing staff, and other staff on documentation issues and resolves provider queries prior to patient discharge.
• Monitors provider documentation queries for timely and compliant response and escalates issues.
• The responsibilities listed are a general overview of the position and additional duties may be assigned.

TECHNICAL CAPABILITIES
• Relationship Management: Manages internal and external organizational relationships with clients, vendors, partners and staff.
• Critical Thinking (Novice): The objective analysis and evaluation of an issue in order to form a judgment.
• Medical Coding (Intermediate): The transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.
• Verbal Communication (Novice): Ability to enunciate clearly, using appropriate voice control and body language. Effectively transmits technical and business ideas and information to others. Listens carefully to ascertain points being made before trying to be understood.
• Written Communication (Novice): Demonstrates the ability to write clear, detailed, and comprehensive status reports, memos and documentation. Demonstrates an understanding of effective composition, such as having first line in a paragraph state the subject.

 Our Nursing Philosophy:  

We believe highly skilled and specialized nursing care is essential to Vanderbilt University Medical Center’s mission of quality in patient care, education and research. We believe nursing is an applied art and science focused on helping people, families and communities reach excellent health and well-being. 

As a Vanderbilt University Medical Center employee, you make a difference to our patients and their families by bringing compassion and care to those in need of hope and healing. Please see our current employee benefits offered:

• Affordable High Quality Health Plan Options
• Dental and /or vision plan
• 403 (b) retirement plan
• Paid Time off (flex PTO)
• Tuition Reimbursement and adoption assistance (maximums applied)
• Short-Long term disability
• Subsidized backup childcare
• And many more... Ask us about our current inpatient nursing supplemental Pay Program!

Achieve the Remarkable: 

Learn more about VUMC Nursing: 

• Nursing Careers: http://www.vumcnursingcareers.com/index.html
• Benefits: http://www.vumcnursingcareers.com/benefits.html  
• Our Nursing Philosophy: http://www.vumcnursingcareers.com/philosophy.html  
• Our Nursing Leadership: http://www.vumcnursingcareers.com/leadership.html  
• Shared Governance: http://www.vumcnursingcareers.com/shared-governance.html 
• Education& Professional Development: http://www.vumcnursingcareers.com/professional-development.html  
• Life In Nashville: http://www.vumcnursingcareers.com/nashville.html  
• VUMC Nursing: http://www.mc.vanderbilt.edu/root/vumc.php?site=vanderbilt-nursing  

Core Accountabilities:

Organizational Impact: Independently delivers on objectives with understanding of how they impact the results of own area/team and other related teams. Problem Solving/ Complexity of work: Utilizes multiple sources of data to analyze and resolve complex problems; may take a new perspective on existing solution. Breadth of Knowledge: Has advanced knowledge within a professional area and basic knowledge across related areas. Team Interaction: Acts as a "go-to" resource for colleagues with less experience; may lead small project teams.

Core Capabilities :

Supporting Colleagues: - Develops Self and Others: Invests time, energy, and enthusiasm in developing self/others to help improve performance e and gain knowledge in new areas. - Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships. - Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences. Delivering Excellent Services: - Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them. - Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions. - Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness. Ensuring High Quality: - Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly. - Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them. - Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring. Managing Resources Effectively: - Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure. - Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area. - Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities. Fostering Innovation: - Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches. - Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges. - Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.

Position Qualifications:

Responsibilities:

Certifications:

LIC-Registered Nurse - Licensure-Others

Work Experience:

Relevant Work Experience

Experience Level:

3 years

Education:

Graduate of an approved discipline specific program

Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and to the principles of equal opportunity and affirmative action. EOE/AA/Women/Minority/Vets/Disabled