CLINICAL DOCUMENTATION SPECIALIST

Location: Columbia, Missouri or Remote

Shift:  Monday - Friday, days

Department: Clinical Documentation Improvement

Salary Range: $56,597 - $89,419/year - final salary based on experience

ABOUT THE JOB

MU Health Care is actively seeking a Clinical Documentation Specialist who is passionate about the power of documentation in revolutionizing patient care. In this pivotal role, you'll champion impeccable ICD-9-CM coding, ensuring that our healthcare documentation practices set the industry standard. Your expertise in data analysis and trend identification will drive efficiency and precision in our documentation workflows. Collaborating closely with physicians and practitioners, you'll be the driving force behind our commitment to elevating the quality of patient records. If you're ready to make a significant impact through the art of documentation, join us in shaping the future of healthcare documentation and transforming patient outcomes.

ABOUT MU HEALTH CARE  
MU Health Care is a growing academic health system in mid-Missouri comprised of multiple hospitals — including the region’s only Level 1 Trauma Center and region’s only Children’s Hospital — and over 50 specialty clinics located throughout the region.
As an MU Health Care employee, you’ll be part of an exceptional team committed to our mission of saving and improving lives. Our core values of inclusion, respect, service, discovery, responsibility and excellence foster a collaborative work environment where you can grow your career.

Learn more about MU Health Care.                Learn more about living in Columbia, MO.

EMPLOYEE BENEFITS

Health, vision and dental insurance coverage starting day one 

Generous paid leave and paid time off, including nine holidays 

Multiple retirement options, including 100% matching up to 8% and full vesting in three years

Tuition assistance for employees (75%) and immediate family members (50%) 

Discounts on cell phone plans, rental cars, gyms, hotels and more

See a comprehensive list of benefits here . 

JOB DUTIES

Gathers data, enters data, harvests from databases, compiles information, and prepares reports to facilitate efficient workloads, identifies trends/issues for corrective action.
Creates reports providing: team productivity, physician intradepartmental feedback, project specific data, and identification of trends/issues with coding and documentation accuracy.
Interacts with patient care providers (physicians, APRN’s, PA’s, etc.) by means of in-services, rounding, clarification query requests and personal contacts to ensure quality documentation practices, documentation clarification, documentation policies/procedures and regulations.
Maintains knowledge of current and developing issues and trends in medical coding, and documentation, and outcomes registries.
Maintains knowledge and expertise in electronic software tools (IDX, Cerner, 3M, etc).
Reviews and analyzes inpatient or outpatient medical records for quality documentation practices resulting in accurate and compliant queries as needed to assist in ICD-9 and ICD-10 coding assignments or outcomes registries.
Works collaboratively with coding staff for determining principal diagnoses, DRG, CPTs, and severity scorings.
Other duties as assigned, including special projects assigned by organizational leadership.
May complete unit/department specific duties and expectations as outlined in department documents.

KNOWLEDGE, SKILLS, & ABILITIES 

Skill in interactive cross-departmental relationships.

Ability to communicate effectively orally, and in writing, and before audiences.

Experience in documentation review, quality, ICD-10 coding, and Current Procedural Technology CPT’s.
Respiratory Care Practitioner (RCP) or (RCP-T) licensure by the Missouri Respiratory Care board; OR
Missouri Board of Nursing RN, or Nurse Licensure Compact multi-state RN. When primary state of residency changes, compact state RNs must apply under new state of residency within thirty (30) days.

Preferred Qualifications
Broad clinical expertise and direct contact with physicians.
Additional license/certification requirements as determined by the hiring department.

Physical Demands
The physical demands described here are representative of those that must be met with or without reasonable accommodation. The performance of these physical demands is an essential function of the job. The employee may be required ambulate, remain in a stationary position and position self to reach and/or move objects above the shoulders and below the knees. The employee may be required to move objects up to 10 lbs.

Equal Opportunity Employer

The University of Missouri System is an Equal Opportunity Employer. Equal Opportunity is and shall be provided for all employees and applicants for employment on the basis of their demonstrated ability and competence without unlawful discrimination on the basis of their race, color, national origin, ancestry, religion, sex, pregnancy, sexual orientation, gender identity, gender expression, age, disability, or protected veteran status, or any other status protected by applicable state or federal law. This policy applies to all employment decisions including, but not limited to, recruiting, hiring, training, promotions, pay practices, benefits, disciplinary actions and terminations. For more information, visit https://www.umsystem.edu/ums/hr/eeo.
All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex, pregnancy, sexual orientation, gender identity, gender expression, age, disability, or protected veteran status, or any other status protected by applicable state or federal law.