Clinical Documentation Specialist
Employment Type : Full-Time
What You Will Do:
University of Maryland Medical Center(UMMC) has achieved Magnet status in recognition of the hospital nursing excellence. UMMC is a teaching hospital with 757 beds based in Baltimore, Maryland, that provides the full range of health care. It has more than 35,000 inpatient admissions and 165,000 outpatient visits each year. The R Adams Cowley Shock Trauma Center (also known as Shock Trauma) is the world's first center dedicated to saving lives of people with severe, life-threatening injuries sustained in motor vehicle collisions, violent crimes and other traumatic incidents. Our vision is to provide high value and compassionate care, improving health in Maryland and beyond, educating future health care leaders and discovering innovative ways to advance medicine worldwide.
Be Part of Something Greater!
Responsibilities/Tasks
- Reviews inpatient medical records both concurrently and retrospectively for identified payer populations as directed on admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.
- Communicates with attending physician / nurse practitioner either verbally or through written methodology to validate observations with intent to clarify unclear, incomplete, ambiguous, inconsistent or unspecified documentation. Works to add detail and/or acuity to a vague or implied diagnoses, verify if a diagnoses was Present On Admission (POA), and establish clinical significance and suspected etiology of a finding.
- Works concurrently to ensure documentation of discharge diagnosis (es) and any co-existing co-morbidities are a complete reflection of the patient’s clinical status and care.
- Evaluates medical record documentation using knowledge about HIM Standards of coding.
- Consistently meets established productivity targets for record review. This includes but is not limited to: chart reviews, chart re-reviews, APR/DRG match, query compliance, and impact, etc.
- In collaboration with physician/Nurse Practioner leadership, departments and team, assists with development and implementation of specific tools/education to support medical record physician / Nurse Practitioner documentation.
- Participates in both formal and informal education sessions with physician, nurse practitioner, nursing, HIM and other clinical staff. Educates on the importance of documentation, necessary verbiage, and to provide a better understanding of what certain codes mean.
- Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
- Acts as clinical liaison between HIM / coding staff and physician / nurse practitioners.
- Attends service line clinical program meetings and CDI meetings as requested.
- Assists with the completion of CDI Retrospective documentation through meetings with physicians/nurse practitioners for query response and/or documentation clarification.
What You Need to Be Successful:
- Bachelor’s degree in Nursing or equivalent is required.
- Current RN license in the State of Maryland, or eligible to practice due to Compact state agreements outlined through the MD Board of Nursing, is required
- Five years’ experience as a Registered Nurse required.
- Experience in Chart Review, Case Management, Utilization Review, Medical Record or coding experience is preferred.
We are an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.