Clinical Documentation Specialist
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Job Description
Clinical Documentation Specialist at UAMS improving clinical documentation quality for patient care. Responsible for ensuring accurate coding and compliance with healthcare regulations.
Responsibilities:
- Responsible for improving overall quality and completeness of clinical documentation
- Ensure that the information in the medical record accurately reflects the patient's severity of illness, clinical needs, and utilization of resources
- Review death medical records to ensure the severity of illness and risk of mortality has been captured at the highest level
- Work with the providers of care to capture the clinical care in a code format for reimbursement and to ensure UAMS has the correct case mix
- Review all admission types to the hospital to ensure severity is captured and then educate the providers of care on admission types.
Requirements:
- Registered Nurse (RN) with current license plus 4 years inpatient clinical experience in Emergency, Critical Care, or Medical/Surgical area with experience in Quality, Case Management, Clinical Audit, or Data Abstraction OR Coding professional with CCS certification and 6 years of inpatient coding experience with documented education in anatomy/physiology and pharmacology.
- CCDS is required within 6 months of hire
Benefits:
- Health: Medical, Dental and Vision plans available for qualifying staff and family
- Holiday, Vacation and Sick Leave
- Education discount for staff and dependents (undergraduate only)
- Retirement: Up to 10% matched contribution from UAMS
- Basic Life Insurance up to $50,000
- Career Training and Educational Opportunities
- Merchant Discounts
- Concierge prescription delivery on the main campus when using UAMS pharmacy
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