Quality & Operational Improvement Engineer

About the Role

The Clinical Documentation Improvement (CDI) program at UI Health Care has an opening for a full-time (100%) Clinical Documentation Specialist. The primary purpose of CDI is concurrent review of the medical record to increase the accuracy, clarity, and specificity of provider documentation. CDI Specialists bridge the gap between providers and hospital coders to clarify at-risk documentation to ensure accurate claim submission.

Key Responsibilities

• Establishes effective and collaborative relationships with members of the hospital community to improve accuracy and completeness of acute inpatient documentation, especially with providers, Health Information Management coding staff, hospital administration, and other patient caregivers.
• Demonstrates knowledge of MS-DRGs, APR-DRGs, documentation opportunities, clinical documentation requirements, and inpatient quality/safety metrics.
• Consistently attends huddles or rounds on units, as directed by department leadership.
• Provides consistent education on clinical documentation opportunities, hospital coding and/or reimbursement issues, as well as performance improvement methodologies to all members of the hospital community.
• Conducts record reconciliation and communicates effectively with hospital coding staff to assign an appropriate working DRG.
• Documents appropriately in the 3M© Clinical Documentation Improvement module.
• Demonstrates an understanding of the importance of capturing all potential secondary diagnoses for coding purposes.
• Maintains thorough and current knowledge of clinical care and treatment of assigned patient populations to critically assess appropriateness of documentation.
• Complies with departmental standards regarding attendance, documentation, departmental workflows, continuous quality improvement and statistics, departmental policies and procedures, and the Code of Ethics.
• Effectively collaborates and respectfully communicates with fellow CDI team members, the hospital coding team, and quality-driven workgroups to ensure appropriate CDI practices and accurate application of coding/documentation principals.
• Actively participates in office and/or intradepartmental committees.
• Performs other projects or responsibilities as assigned.
• This position does not have direct patient care responsibilities.

CDI Chart Reviews Include

• New acute inpatient admissions to the facility.
• Identifies and re-reviews high priority charts every two days or as needed.
• Retrospective reviews for query identification, documentation clarification, denials, or quality measures.
• Completes quality reviews focused on CDI quality elements, such as Mortality, Hospital Acquired Conditions (HAC), and other publicly reported patient quality or safety metrics (i.e., AHRQ Patient Safety Indicators).

Requirements & Tech Stack

• Bachelor’s degree in nursing or a master's degree in nursing (MNHP or MSN), or an equivalent combination of education in a related field and experience.
• A current license to practice nursing in Iowa.
• Previous work experience (within the last 5 years) as a Clinical Documentation Specialist.
• Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire.
• Proficiency with computer software applications (i.e., Microsoft applications).
• 3M© Clinical Documentation Improvement module.

Qualifications

• Professional written and verbal communication skills.
• Demonstrates the ability to provide effective education in a variety of styles, including formal presentations.
• Demonstrates excellent interpersonal skills with physicians, nursing staff, and interdisciplinary team members as demonstrated through written and verbal communication.
• Demonstrated organizational, time management, and problem-solving skills.
• Experience with performance improvement methodologies (Desired).
• Experience improving and/or reviewing hospital quality/safety metrics (Desired).
• Experience with data mining and/or data analytics (Desired).
• Advanced certification (i.e., CCDS, CDIP, CPHQ) (Desired).

Work Schedule & Location

• Full-time (100%).
• Flexible between the hours of 8:00 AM - 4:30 PM, Monday through Friday.
• Hybrid within Iowa is an option after initial training and onboarding. Remote work must be performed within the state of Iowa.

Compensation & Benefits

• Pay Level: 5A.
• Fringe benefit package including paid vacation; sick leave; health, dental, life, and disability insurance options; and generous employer contributions into retirement plans.