Clinical Nursing Consultant II- Clinical Documentation Improvement Specialist

at  University of Illinois

CLINICAL NURSING CONSULTANT II- CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST

Hiring Department: Clinical Nursing Consultant II- Clinical Documentation Improvement Specialist
Location: Chicago, IL USA
Requisition ID: 1028002
Posting Close Date: 11/01/2024
Workshift: Days
Workschedule: Monday-Friday

DESCRIPTION:

Position Summary The Clinical Documentation Specialist facilitates the improvement in the overall quality, completeness, and accuracy of clinical documentation in the medical record. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, and Health Information Management coding staff. Ensures that the clinical severity and risk of mortality for the level of services provided are appropriately documented for inpatient accounts. Educates members of the patient care team on documentation guidelines on an ongoing basis. Duties & Responsibilities • Clinical Documentation Improvement/Quality/Education • Facilitates appropriate clinical documentation to ensure that the level of services and acuity of illness are accurately reflected in the medical record. • Improves overall quality and completeness of clinical documentation for identified patient populations. • Demonstrates knowledge of MS-DRG and APR-DRG payer issues, documentation opportunities, clinical documentation requirements, coding, policies and procedures, and quality measures. • Improves the overall quality and completeness of clinical documentation by performing admission/continued stay reviews using clinical documentation guidelines for selected patient populations. • Formulates compliant and credible clinical documentation clarifications or queries to improve clinical documentation of principal diagnosis, co-morbidities, clinical severity and risk of mortality, present on admission (POA), quality core measures, and patient safety indicators (PSI). • Updates worksheet to reflect any changes in patient status, procedures/treatments, and confers with the physician to finalize diagnoses as required. • Conducts timely follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been recorded in the patient’s chart. • Collaborates with the coding staff concurrently and retrospectively and reviews clinical issues as needed with the Coding Staff for the accuracy of coding. • Responsible for accurate, timely entry of pertinent data. • Assumes the responsibility for achieving program objectives. • Maintains positive communication with physicians, CDI team members, and management. • Assists in special projects as required. • Collaborates with other nurses and physicians to identify, promote, and provide positive learning experiences for providers. • Provides CDI education to nursing staff, and Allied Health Professionals as appropriate. • Initiates one-on-one physician education interaction as indicated for clarification and documentation needs. • Assists in the development of educational presentations to medical providers for awareness of documentation requirements. • Provides clinical information and education to coding staff as needed. • Assists Clinical Documentation Improvement Director in providing education to Physician Liaisons regarding medical payment systems, coding rules, and healthcare reporting. • Professional/Leadership • Participates in organizational, departmental, and shared leadership activities; supports department goals in daily behavior. • Demonstrates accountability for job performance by (1) seeking opportunities to enhance job skills and knowledge; and (2) maintaining conditions of employment (RN licensure, CCDS, and other required certifications). • Demonstrates a broad scope of clinical expertise. • Demonstrates effective time management skills. • As needed, recommends quality and/or performance improvement initiatives to more effectively and efficiently perform job functions. • Accesses Medical Center intranet for relevant communication and to review and interpret changes in policy, procedure, and other information pertinent to the role. • Takes responsibility for continued professional growth/development by identifying learning needs and initiating strategies to meet such needs.

MINIMUM QUALIFICATIONS

1. Graduation from an accredited school of nursing.
2. Current license as a Professional Registered Nurse from the State of Illinois
3. Minimum of 3 years of acute care bedside nursing experience
4. Minimum of 3 years of Clinical Documentation Improvement experience in the acute care setting
5. Bachelor’s Degree in Nursing (BSN) with CDI and acute care bedside nursing experience.
6. Current AHA BLS/CPR and other required unit specific certifications
7. Strong interpersonal and effective communication skills (oral and written), conflict management, and negotiation skills.
8. Effective communication skills (oral and written) that facilitate therapeutic relationships between patients, family, and health care providers
9. Analytical skills necessary to independently collect, analyze, and interpret clinical data.
10. Intermediate computer skills with the ability to become proficient in the Electronic Health Record (EHR) with on-the-job training

PREFERRED QUALIFICATIONS

1. Five years of experience in medical/surgical, critical care, intensive care, or emergency care
2. Extensive knowledge and experience in ICD-10 coding classification and DRG system and Quality Measures.
3. CCDS certification
4. Master’s Degree
   The University of Illinois System is an equal opportunity employer, including but not limited to disability and/or veteran status, and complies with all applicable state and federal employment mandates. Please visit Required Employment Notices and Posters to view our non-discrimination statement and find additional information about required background checks, sexual harassment/misconduct disclosures, and employment eligibility review through E-Verify.
   The university provides accommodations to applicants and employees. Request an Accommodation

Please refer the Job description for details