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UAB St. Vincent's

Clinical Documentation Specialist - PRN

Posted an hour ago
2-5 years experience
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AI Summary

The Clinical Documentation Specialist facilitates the improvement of medical record quality, completeness, and accuracy by assigning working Diagnosis Related Groups. They collaborate with healthcare providers to ensure severity of illness and services are accurately reflected in documentation prior to patient discharge.

Position Overview

  • Department:  Clinical Documentation Integrity
  • Schedule:  PRN (0500-2100 flexible) minimium 8hrs every 2 weeks
  • Work Location: UAB St Vincent's Birminging - Remote

Preferred Qualifications: 

  • CCDS or CDIP certification preferred
  • Minimum of three years of CDI experience

What You Will Do

Facilitate improvement in overall quality, completeness and accuracy of medical record documentation.

  • Complete admission reviews and assign a working Diagnosis Related Group. Ensure the working DRG and other information are entered in the Clinical Documentation Improvement database.
  • Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
  • Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge.
  • Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.

What You Will Need

Licensure / Certification / Registration:

  • One or more of the following required:
    • Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
    • Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.
    • Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
    • Licensed Registered Nurse credentialed from the Alabama Board of Nursing obtained prior to hire date or job transfer date.
    • Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
    • Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.

Education:

  • High School diploma equivalency with 2 years of cumulative experience OR Associate'sdegree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.

Additional Preferences

No additional preferences.

About UAB St. Vincent’s

UAB St. Vincent’s, a proud part of UAB Medicine, is a trusted provider of health care, serving Alabama for more than 125 years. With five hospitals and numerous clinics, we're a health care community deeply rooted in compassion, service, and respect for all, guided by the rich legacy of the St. Vincent’s name. We're committed to extending kindness and personalized care to patients, their families, and each other. We address the physical, psychological, social, and spiritual needs of our patients. We believe in the power of teamwork and unity, and foster a collaborative spirit among our more than 4,800 employees. As one of Alabama’s best hospitals as recognized by U.S. News & World Report, improving the health and lives of those we serve is at the heart of our mission. Join us in continuing our legacy of service and healing in central Alabama, where we can make a lasting impact together.

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