Discover Vanderbilt University Medical Center: Located in Nashville, Tennessee, and operating at a global crossroads of teaching, discovery, and patient care, VUMC is a community of diverse individuals who come to work each day with the simple aim of changing the world. It is a place where your expertise will be valued, your knowledge expanded, and your abilities challenged. Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and where your diversity of culture, thinking, learning, and leading is sought and celebrated. It is a place where employees know they are part of something that is bigger than themselves, take exceptional pride in their work and never settle for what was good enough yesterday. Vanderbilt's mission is to advance health and wellness through preeminent programs in patient care, education, and research.

Organization:

HIM - CDE - 2

Job Summary:

JOB SUMMARY
Under direction, responsible for daily CDE work flow analysis and coordination of program resources. With support, ensure that the appropriate infrastructure is in place to support, maintain and achieve overall documentation excellence and compliance to support accurate program metrics and appropriate reimbursement. Works with physicians and staff to promote best documentation practices to ensure capture of discharge diagnosis(es), including any co-existing co-morbidities, and procedures in order to accurately reflect the patient's clinical status and care provided. Performs concurrent review of patient records for optimum documentation to support accurate assignment.

.

REQUIREMENTS:

• A minimum of 3 years working as a Clinical Documentation Specialist
• Registered Nurse Required
• Excellent written and oral communication skills
• Strong understanding of inpatient coding and reimbursement
• Proficient with Microsoft Office Suite of Applications especially Excel, Word, and PowerPoint
• Experience with 3M 360 preferred
• Epic Medical Record System experience preferred
• Clinical Documentation Specialist certification (ACDIS) preferred.
• Proficient with the use of Microsoft products (Excel, WORD, PowerPoint, Outlook) required.
• Epic Medical Record System experience preferred

KEY RESPONSIBILITIES:

• Performs assessment of patient records to evaluate documentation for accuracy, legibility and completeness as they relate to assignment of codes, MS-DRGs and APR-DRGs.
• Supports QSRP and external reporting initiatives through concurrent review of medical record documentation
• Works closely with coding staff to ensure documentation of discharge diagnoses and procedures are complete.
• Communicates with physicians regarding missing, unclear, or conflicting clinical documentation.
• Collaborates with case managers, nursing staff, and other ancillary staff.
• Monitors provider documentation queries for timely and compliant response and escalates issues.

TECHNICAL CAPABILITIES:

MEDICAL CODING (INTERMEDIATE): - The transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes. ICD- 10- CM and PCS coding skills.

MEDICAL TERMINOLOGY & DOCUMENTATION (ADVANCED):- The ability to comprehend medical terminology, anatomy & physiology, and pharmacology treatments in an inpatient hospital setting.

CRITICAL THINKING (ADVANCED):- The objective analysis and evaluation of an issue in order to form a judgment.

COMPLIANCE (ADVANCED):- Understanding the rules, regulations, sanctions and other statutory requirements, guidelines and instructions relating to governing bodies and organizations, both internally and externally.

VERBAL COMMUNICATION (ADVANCED):- Ability to enunciate clearly, using appropriate voice control and body language. Effectively transmits technical and business ideas and information to others. Listens carefully to ascertain points being made before trying to be understood.

WRITTEN COMMUNICATION (ADVANCED): - Demonstrates the ability to write clear, detailed, and comprehensive status reports, memos, and documentation. Demonstrates an understanding of effective composition, such as having first line in a paragraph state the subject.

PEER LEADERSHIP (INTERMEDIATE): - The ability to show leadership and influence people of equal rank to accomplish team goals.

Qualifications

Graduate of an approved discipline specific program (or equivalent experience) and 5 years relevant experience.

Licensure, Certification, and/or Registration (LCR):

• Registered Nurse Required

Additional Qualification Information:

• Industry certification in clinical documentation improvement (e.g., CDIP, CCDS) preferred.

Our professional administrative functions include critical supporting roles in information technology and informatics, finance, administration, legal and community affairs, human resources, communications and marketing, development, facilities, and many more.

At our growing health system, we support each other and encourage excellence among all who are part of our workforce. High-achieving employees stay at Vanderbilt Health for professional growth, appreciation of benefits, and a sense of community and purpose.

Core Accountabilities:

Organizational Impact: Independently delivers on objectives with understanding of how they impact the results of own area/team and other related teams. Problem Solving/ Complexity of work: Utilizes multiple sources of data to analyze and resolve complex problems; may take a new perspective on existing solution. Breadth of Knowledge: Has advanced knowledge within a professional area and basic knowledge across related areas. Team Interaction: Acts as a "go-to" resource for colleagues with less experience; may lead small project teams.

Core Capabilities :

Supporting Colleagues: - Develops Self and Others: Invests time, energy, and enthusiasm in developing self/others to help improve performance e and gain knowledge in new areas. - Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships. - Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences. Delivering Excellent Services: - Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them. - Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions. - Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness. Ensuring High Quality: - Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly. - Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them. - Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring. Managing Resources Effectively: - Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure. - Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area. - Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities. Fostering Innovation: - Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches. - Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges. - Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.

Position Qualifications:

Responsibilities:

Certifications:

LIC-Registered Nurse - Licensure-Others

Work Experience:

Relevant Work Experience

Experience Level:

3 years

Education:

Graduate of an approved discipline specific program

Vanderbilt Health recognizes that diversity is essential for excellence and innovation. We are committed to an inclusive environment where everyone has the chance to thrive and to the principles of equal opportunity and affirmative action. EOE/AA/Women/Minority/Vets/Disabled