This position is eligible to participate in partial remote work after initial training and onboarding has been completed. Remote work must be performed at a location within the state of Iowa. Successful candidates who participate in remote work must comply with requirements of the remote work program and related policies.

Position Summary:

The Office of Clinical Documentation Improvement (CDI) at the University of Iowa Hospitals & Clinics has multiple openings for full-time Clinical Documentation Specialists. The primary purpose of Clinical Documentation Improvement (CDI) is concurrent review of the medical record to increase the accuracy, clarity, and specificity of provider documentation (Association of Clinical Documentation Improvement Specialists, ACDIS).

Clinical Documentation Specialists bridge the gap between the providers and hospital coders to clarify at-risk documentation to ensure accurate claim submission (American Health Information Management Association, AHIMA). CDI chart reviews include:

• New acute inpatient admissions to the facility
• Identifies and re-reviews high priority charts every two days or as needed
• Retrospective reviews for query identification, documentation clarification, denials, or quality measures.
• Completes quality reviews focused on CDI quality elements, such as Mortality, Hospital Acquired Conditions (HAC), and other publicly reported patient quality or safety metrics (i.e. AHRQ Patient Safety Indicators)

When provider documentation is illegible, incomplete, imprecise, inconsistent, conflicting, or unreliable the Clinical Documentation Specialist is expected to communicate (i.e. query) with the provider to obtain the necessary information to clarify the medical record (AHIMA, 2014).

The Clinical Documentation Specialist must hold a general proficiency within both the clinical and hospital coding skill sets. The Clinical Documentation Specialist provides the geometric mean length of stay (GMLOS) associated with the working DRG to identify the expected length of stay for acute inpatients.

This position does not have direct patient care responsibilities.

The successful candidate will have:

• A Bachelor’s degree in Nursing or a Master's degree in Nursing (MNHP or MSN)
• An Iowa nursing license
• Thre years of recent inpatient nursing experience in a medical-surgical, and/or ICU setting, and/or recent work experience as a Clinical Documentation Specialist, CDI nurse, or healthcare quality professional with specific medical record review experience
• Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire.

Job Duties and Responsibilities:

• Establishes effective and collaborative relationships with members of the hospital community to improve accuracy and completeness of acute inpatient documentation, especially with providers, Health Information Management coding staff, hospital administration, and other patient caregivers.
• Demonstrate knowledge of MS-DRGs, APR-DRGs, documentation opportunities, clinical documentation requirements, and inpatient quality/safety metrics.
• Consistently attend huddles or rounds on units, as directed by department leadership.
• Provides consistent education on clinical documentation opportunities, hospital coding and/or reimbursement issues, as well as performance improvement methodologies to all members of the hospital community.
• Conduct record reconciliation and communicates effectively with hospital coding staff to assign an appropriate working DRG.
• Documents appropriately in the 3M© Clinical Documentation Improvement module.
• Demonstrates an understanding of the importance of capturing all potential secondary diagnosis for coding purposes.
• Maintains thorough and current knowledge of clinical care and treatment of assigned patient populations to critically assess appropriateness of documentation.
• Comply with departmental standards regarding attendance, documentation, departmental workflows, continuous quality improvement and statistics, departmental policies and procedures, and the Code of Ethics.
• Effectively collaborates and respectfully communicates with fellow CDI team members, the hospital coding team, and quality-driven workgroups to ensure appropriate CDI practices and accurate application of coding/documentation principals.
• Actively participate in office and/or intradepartmental committees.
• Performs other projects or responsibilities as assigned.

Percent of Time: 100% (full-time)
Work schedule: 8:00 AM and 4:30 PM, Monday through Friday
Location: University of Iowa Hospitals & Clinics, 200 Hawkins Drive, Iowa City, IA
Starting salary: $51,012 to commensurate (based on qualifications and related/relevant experience)
Pay level 5A; to view the full pay range for 5A: https://hr.uiowa.edu/pay/pay-plans/professional-and-scientific-pay-structure

About the University of Iowa Hospitals & Clinics:
The University of Iowa Hospitals & Clinics—recognized as one of the best hospitals in the United States—is Iowa's only comprehensive academic medical center and a regional referral center. Each day more than 12,000 employees, students, and volunteers work together to provide safe, quality health care and excellent service for our patients. Simply stated, our mission is: Changing Medicine. Changing Lives.®

Living in the Iowa City area:
The University of Iowa Hospitals & Clinics is located along the picturesque Iowa River in Iowa City, a city of some 77,000 people (170,000+ in the metro area) regularly ranked as one of the nation’s best places to live. Iowa City is less than four hours from Chicago and within five hours of Minneapolis, St. Louis, and Kansas City, readily accessible via interstate highways and a regional airport 30 minutes away.

Benefits Highlights:

• Regular salaried position located in Iowa City, Iowa
• Fringe benefit package including paid vacation; sick leave; health, dental, life and disability insurance options; and generous employer contributions into retirement plans. Complete information regarding the full benefits package may be viewed at: https://hr.uiowa.edu/benefits
• For more information about Why Iowa?, click here