Clinical Documentation Specialist - PRN

About This Role

This PRN role in Clinical Documentation Integrity focuses on improving the overall quality, completeness, and accuracy of medical record documentation. It involves extensive interaction with physicians and mid-level providers to ensure accurate reflection of patient care and to resolve documentation issues.

Responsibilities

• 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
• 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

Requirements

• High School diploma equivalency with 2 years of cumulative experience OR Associate's degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience
• 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 Professional 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
  • Registered Health Information Administrator credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date
  • Registered Health Information Technician credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date

Nice to have:

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

Important Details

• Schedule: PRN (0500-2100 flexible) minimum 8 hours every 2 weeks
• Work locations: UAB St Vincent's Birmingham - Remote

About the Company

UAB Medicine is Alabama’s largest and most comprehensive health system, recognized nationally for delivering world-class patient care, pioneering research, and cutting-edge medical education. It serves over 1.2 million patients annually from every county in Alabama, all 50 states, and many countries worldwide. The network includes numerous hospitals, emergency departments, and other care sites, with a team of over 2,000 physicians. Key facilities include UAB Hospital, ranked the No. 1 hospital in Alabama by U.S. News & World Report, and five UAB St. Vincent’s hospitals serving central Alabama.