Clinical Documentation Specialist

Shift
:
Monday – Friday, 8am – 4pm

Department
:
Clinical Documentation Integrity - Available as Remote

Compensation
:
Base Pay Range: $56,596 - $89,419 per year, based on experience

MU Health Care is actively seeking a Clinical Documentation Specialist who is passionate about the power of documentation in revolutionizing patient care. In this pivotal role, you'll champion impeccable ICD-9-CM coding, ensuring that our healthcare documentation practices set the industry standard. Your expertise in data analysis and trend identification will drive efficiency and precision in our documentation workflows. Collaborating closely with physicians and practitioners, you'll be the driving force behind our commitment to elevating the quality of patient records.

If you're ready to make a significant impact through the art of documentation, join us in shaping the future of healthcare documentation and transforming patient outcomes.

MU Health Care is proud to be named one of Forbes’ Best-in-State Employers seven years in a row, and that’s largely a result of the incredible culture and team we’ve built. At MU Health Care, we have an inspired, hard-working and collaborative environment driven by our mission to save and improve lives. Here, we believe anything is possible and rally around solutions.

We celebrate innovation and offer opportunities to be a part of something bigger — to have a voice and role in the work that is serving our community and changing the field of medicine.

Our academic health system — the only one in mid-Missouri — is home to seven hospitals, including the region’s only Level 1 Trauma Center and region’s only Children’s Hospital, as well as over 90 specialty clinics. Here you can define your career among our many clinical and nonclinical positions — with growth, opportunity and support every step of the way.

• Health, vision and dental insurance coverage starting day one
• Generous paid leave and paid time off, including nine holidays
• Multiple retirement options, including 100% matching up to 8% and full vesting in three years
• Tuition assistance for employees (75%) and immediate family members (50%)
• Discounts on cell phone plans, rental cars, gyms, hotels and more
• See a comprehensive list of benefits here.

Gathers data, enters data, harvests from databases, compiles information, and prepares reports to facilitate efficient workloads, identifies trends/issues for corrective action.

Creates reports providing team productivity, physician intradepartmental feedback, project specific data, and identification of trends/issues with coding and documentation accuracy.

Interacts with patient care providers (physicians, APRN’s, PA’s, etc.) by means of in‑services, rounding, clarification query requests and personal contacts to ensure quality documentation practices, documentation clarification, documentation policies/procedures and regulations.

Maintains knowledge of current and developing issues and trends in medical coding, and documentation, and outcomes registries.

Maintains knowledge and expertise in electronic software tools (IDX, Cerner, 3M, etc.).

Reviews and analyzes inpatient or outpatient medical records for quality documentation practices resulting in accurate and compliant queries as needed to assist in ICD-9 and ICD-10 coding assignments or outcomes registries.

Works collaboratively with coding staff for determining principal diagnoses, DRG, CPTs, and severity scorings.

Other duties as assigned, including special projects assigned by organizational leadership.

May complete unit/department specific duties and expectations as outlined in department documents.

Skill in interactive cross-departmental relationships.

Ability to communicate effectively orally, and in writing, and before audiences.

Experience in documentation review, quality, ICD-10 coding, and Current Procedural Technology CPT’s.

Respiratory Care Practitioner (RCP) or RCP‑T licensure by the Missouri Respiratory Care board; OR

Missouri Board of Nursing RN, or Nurse Licensure Compact multi-state RN. When primary state of…