Quality & Operational Improvement Engineer - Clinical Documentation Improvement

The University of Iowa hires a Clinical Documentation Specialist for its UI Health Care Clinical Documentation Improvement program. The role reviews acute inpatient records, clarifies provider documentation, supports accurate coding and claims, and contributes to documentation education and quality review.

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
• This position does not have direct patient care responsibilities

Requirements:

• A bachelor's degree in nursing or a master's degree in nursing (MNHP or MSN), or an equivalent combination of education in a related field and experience is required
• A current license to practice nursing in Iowa is required
• Previous work experience (within the last 5 years) as a Clinical Documentation Specialist is required
• Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire
• Professional written and verbal communication skills are required
• Demonstrates the ability to provide effective education in a variety of styles, including formal presentations
• Proficiency with computer software applications (i.e., Microsoft applications) is required
• Demonstrates excellent interpersonal skills with physicians, nursing staff, and interdisciplinary team members as demonstrated through written and verbal communication is required
• Demonstrated organizational, time management and problem-solving skills are required
• This position is not eligible for University of Iowa sponsorship for employment authorization
• Experience with performance improvement methodologies
• Experience improving and/or reviewing hospital quality/safety metrics
• Experience with data mining and/or data analytics
• Advanced certification (i.e., CCDS, CDIP, CPHQ)