Nurse Specialist, Clinical Documentation Improvement

Nurse Specialist, Clinical Documentation Improvement

Apply for the Nurse Specialist, Clinical Documentation Improvement role at University of Utah Health.

Location:

Salt Lake City, UT.

As a patient‑focused organization, University of Utah Health exists to enhance the health and well‑being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. The organization seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, integrity, quality and trust. EO/AA.

This position is responsible for improving the overall quality and completeness of clinical documentation by communicating with and providing education to physicians, case managers, coders and other health team members. The role may be required to access and administer medications within scope of practice and per state law.

Corporate Overview:
The University of Utah is a Level 1 Trauma Center and is nationally ranked for its academic research, quality standards and overall patient experience. Five hospitals and eleven clinics provide excellence in comprehensive services, medical advancement and patient outcomes.

• Ensure documentation meets quality standards and accurately reflects the patient’s status.
• Provide education to staff and physicians on the importance of the Clinical Documentation Improvement Program (CDIP).
• Facilitate modifications to clinical documentation through interactions with physicians, nursing staff, and coding to support appropriate reimbursement and clinical severity capture.
• Support timely, accurate, and complete documentation used for measuring and reporting physician and hospital outcomes.
• Assist assigned coder with reviewing inpatient medical records and discuss documentation opportunities with physician teams.
• Act as consultant to coders when additional information is needed for correct DRG assignment.
• Participate in assigned hospital, unit, and departmental committees.
• Work rotating schedules, which may include variable hours, weekends, nights, and holidays to meet staffing needs of a 24/7 health system.

• Demonstrated ability to perform essential functions.
• Availability to work variable and rotating shifts, including nights, weekends, and holidays.
• Knowledge of state and federal regulations.
• Effective communication and human relations skills.
• Ability to collaborate with coders, physician teams, and hospital staff.
• Ability to identify and monitor trends and opportunities for documentation improvement.

• Five years of clinical and critical nursing experience.
• Bachelor’s degree in Nursing or equivalency.

• Current registered nurse license in the State of Utah; maintain an interstate compact license if residency remains outside Utah.

• Knowledge of ICD‑9 and DRG.

• Sedentary office position; may exert up to 10 pounds and move objects.
• Most time sitting; no exposure to adverse environmental conditions.

Listening, Sitting, Speaking.

Full‑time.

Mid‑Senior level.>