RN, Clinical Document Spec

As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

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ESSENTIAL FUNCTIONS

• Recognizes gaps and facilitates modifications in clinical documentation that support accuracy of medical conditions for inpatient encounter.
• Recognizes documentation opportunities with the assistance of computer software.
• Conducts clinical documentation improvement efforts through query processes.
• Provides oversight for EPARC, including UM work queues and unbilled work queues.
• Communicates with individual physicians and medical team, providing guidance and clarification around principal diagnoses, complicating conditions, and diagnoses being treated to ensure complete and accurate documentation in medical record.
• Presents overall findings to key stakeholders, including leadership and peers.
• Provides education to peers and healthcare team members for documentation improvement, reimbursement opportunities, and overall performance improvement.
• Demonstrates knowledge of trends in clinical diagnoses that results in payer denials.
• Ensures validity of data for reporting and measuring physician and hospital outcomes using computer software and analysis of data.
• Audits clinical documentation to confirm points of clarification have been entered in the medical record.
• Meets established productivity expectations of CDI program.
• Maintains knowledge of hospital clinical practice guidelines to support the most thorough review of the medical record.

Other duties as assigned.

MINIMUM EDUCATION & EXPERIENCE

• Associate's degree Registered Nurse (RN) required
• Bachelor's degree in Nursing preferred
• 5 years inpatient clinical experience, knowledge of complex disease processes required
• Or equivalent combination of education and experience

KNOWLEDGE, SKILLS AND ABILITIES

• Prior experience with EPARC, eRecord, HDM, Cobius, and Sharepoint preferred

LICENSES AND CERTIFICATIONS

• RN - Registered Nurse - State Licensure and/or Compact State Licensure Current RN License in NYS upon hire required

The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.