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Clinical Documentation Specialist
University of Arkansas SystemClinical Documentation Specialist at UAMS improving clinical documentation quality for patient care. Responsible for ensuring accurate coding and compliance with healthcare regulations.
About the role
Key responsibilities & impact- 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
What you’ll need- 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
Comp & perks- 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
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
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Hard Skills & Tools
clinical documentationcodingquality improvementdata abstractionclinical auditanatomyphysiologypharmacology
Soft Skills
communicationeducationcollaboration
Certifications
Registered Nurse (RN)CCSCCDS