Offer summary

Qualifications:

Three years of clinical acute care nursing experience or completion of Health Records Administration program (RHIA) or Accredited Record Technician (RHIT) with three years of experience in DRG selection., Knowledge of DRG, Prospective Payment System, and clinical documentation improvement is essential., Certifications such as Certified Coding Specialist (CCS) or Registered Health Information Administrator (RHIA) are required., Strong communication skills to interact with healthcare professionals and educate on documentation standards..

Key responsabilities:

Facilitate modifications to clinical documentation through interaction with physicians and healthcare team members.

Evaluate medical records daily for accuracy and completeness, including lab results and treatment plans.

Prepare and present trended data to physicians in small group settings.

Participate in clinical documentation improvement initiatives at the organizational level.

Job description

UPMC Corporate Revenue Cycle is hiring a Clinical Documentation Improvement Specialist to join our coding team. This position will be a work-from-home position working Monday through Friday during normal business hours.

The Clinical Documentation Specialist (CDS) facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the healthcare team to ensure appropriate clinical severity is captured for the level of services rendered to all inpatients.

If you are ready to take the next step in your coding career and have experience as a CDI Specialist, look no further!

Responsibilities:

Participating at the organizational level in clinical documentation improvement initiatives
Communicate with physicians, face-to-face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of the severity of illness
Preparing trended data for presentation one-on-one and small to medium groups of physicians
Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team
Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team
Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans
Three years of previous clinical acute care nursing experience medical/surgical experience to include critical care in conjunction with an expanded knowledge of DRG's; OR completion of Health Records Administration program (RHIA) or Accredited Record Technician (RHIT) AND 3 years of experience with the Prospective Payment System and DRG selection; OR specific knowledge as a consultant in Medical Record coding and DRG assignment required.
Prior CDI work experience preferred.
Knowledge of computer technology, quality assurance activities, DRG, and Quality Insights/Utilization review background is highly preferred.
Ability to communicate with staff, physicians, healthcare providers, and other healthcare system personnel in a professional and diplomatic manner required.

Licensure, Certifications, and Clearances:

Certified Coding Specialist (CCS) OR Certified Registered Nurse Practitioner OR Doctor of Medicine (MD) OR Doctor of Podiatric Medicine OR Registered Health Information Administrator OR Registered Health Information Technician (RHIT) OR Registered Nurse (RN)
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Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.
Employees practicing in Maryland: Respiratory Therapist license may be used in substitution of the aforementioned certifications and licensure.

UPMC is an Equal Opportunity Employer/Disability/Veteran

Annual

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