Documentation Specialist jobs in Madison, WI

We're seeking a Clinical Documentation Integrity Specialist (CDIS) RN to join our team! In this role, you'll be responsible for performing concurrent review of medical records to ensure complete and accurate clinical documentation to support severity of illness, risk of mortality for outcomes reporting, and for hospital reimbursement. The position requires a strong attention to detail and process orientation and an ability to think globally about documentation requirements in the medical records. The CDS must communicate effectively in oral and written form to physicians and other clinicians to promote accurate and complete documentation during the patient’s course of care. CDS supports the hospital’s overall compliance efforts designed to ensure the accuracy of diagnosis and procedural coding, Diagnosis Related Group (DRG) assignment, severity of illness (SOI), and expected risk of mortality (ROM).

COVID-19 and Flu Vaccination Requirement: It is required to be fully vaccinated for COVID-19 and Influenza. Exemption requests based on medical or religious reasons may be submitted, but must be approved for active employment.

This position is open to remote/work from home with strong preference for candidates residing within the UPH geographies of Iowa, Illinois, & Wisconsin.

PLEASE NOTE: This position is subject to pre-hire testing.

Why UnityPoint Health?

• Commitment to our Team – We’ve been named a  Top 150 Place to Work in Healthcare 2022  by Becker’s Healthcare for our commitment to our team members.
• Culture – At UnityPoint Health, you matter. Come for a fulfilling career and experience  a culture  guided by uncompromising values and unwavering belief in doing what's right for the people we serve.
• Benefits – Our competitive  Total Rewards  program offers benefits options that align with your needs and priorities, no matter what life stage you’re in.
• Diversity, Equity and Inclusion Commitment – We’re committed to ensuring you have a voice that is heard regardless of role, race, gender, religion, or sexual orientation.
• Development – We believe equipping you with support and  development opportunities  is an essential part of delivering a remarkable employment experience.
• Community Involvement – Be an essential part of our core purpose—to improve the health of the people and communities we serve.

Visit us at UnityPoint.org/careers to hear more from our team members about why UnityPoint Health is a great place to work.  https://dayinthelife.unitypoint.org/ 

Operational

• Conducts reviews of designated medical records to facilitate the creation of a health record that accurately represents the acuity of the patient’s illness and the resources used to treat the patient by ensuring provider documentation supports all applicable diagnosis codes.
• Ensures assignment of the working DRG is supported by diagnostic and procedural findings from the medical record. This will include the identification of secondary diagnosis that may result in Complications and Co-morbidities (CC) and/or Major Complications and Co-morbidities (MCC) assignment.
• Utilizes a compliant query process per guidelines and policies and follows each query through closure including complete documentation of ongoing follow up and communication.
• Maintains integrity and compliance of medical record reviews, clinical documentation integrity documentation, and queries.
• Efficiently and effectively utilizes UnityPoint Health’s selected CDI software and processes (i.e. CDI worksheet and workflow, physician query, query and DRG reconciliation processes).
• Meets the minimum productivity and quality assurance standards established by the CDI department.

Relationship Building/Collaboration

• Collaborates with coding staff and leaders for improved knowledge and understanding of coding guidelines.
• Collaborates with physicians and/or other hospital staff to coordinate work and resolve issues.
• Collaborates with Clinical Documentation Integrity leaders to provide feedback and receive work direction.
• Collaborates with other hospital departments as needed and directed by CDI leaders.

Education:

• RN
• BSN or higher preferred

Experience:

• Three (3) to five (5) years applicable acute care nursing experience
• Previous experience in clinical documentation improvement is preferred.
• Previous experience with chart review or chart auditing is preferred.
• Knowledge of ICD CM/PCS coding guidelines

License(s)/Certification(s):

• Registered Nurse licensure required

• Certified Clinical Documentation Specialist (CCDS) preferred

• Certified Documentation Improvement Practitioner (CDIP) preferred

Knowledge/Skills/Abilities:

• Excellent interpersonal and communication skills
• Knowledge of reimbursement systems, federal, state, and payer specific regulations and policies pertaining to documentation and coding
• Multicultural sensitivity
• Microsoft Office – basic computer skills
• Customer/patient focused
• Critical thinking skills using independent judgment in making decisions
• Action Planning
• Ability to work independently
• Highly motivated, self-starter who works effectively with minimum supervision
• Ability to organize work quickly and efficiently and be comfortable working against deadlines
• Maintain effective working relationships