JOB SUMMARY: Ensures capture of discharge diagnosis and procedures independently. Documents the patient's clinical status and care provided. Performs concurrent review of patient records for documentation to support assignment of clinical codes.
RN licensure (required)
A minimum of 3 years of CDI experience (preferred)
Clinical Documentation Specialist certification ( ACDIS) preferred (CCDS or CDIP)
Proficient with the use of Microsoft products( Excel, WORD, PowerPoint, Outlook) preferred
Previous working experience with Epic systems preferred
Performs assessment of patient records to evaluate documentation for accuracy, legibility and completeness.
Works with coding staff to ensure documentation of discharge diagnoses, including any coexisting co-morbidities, and procedures are complete.
Communicates with providers regarding missing, unclear, or conflicting clinical documentation.
Collaborates with case managers, nursing staff, and other staff on documentation issues and resolves provider queries prior to patient discharge.
Monitors provider documentation queries for timely and compliant response and escalates issues.
The responsibilities listed are a general overview of the position and additional duties may be assigned.
WRITTEN COMMUNICATION (NOVICE): - 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.
MEDICAL CODING (INTERMEDIATE): - The transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.
VERBAL COMMUNICATION (NOVICE): - 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.
CRITICAL THINKING (NOVICE): - The objective analysis and evaluation of an issue in order to form a judgment.
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.
Vanderbilt University Medical Center is home to Vanderbilt University Hospital, The Monroe Carell Jr. Children’s Hospital at Vanderbilt, the Vanderbilt Psychiatric Hospital and the Vanderbilt Stallworth Rehabilitation Hospital. These hospitals experienced more than 61,000 inpatient admissions during fiscal year 2015. Vanderbilt’s adult and pediatric clinics treated nearly 2 million patients during this same period. Vanderbilt University Hospital and the Monroe Carell Jr. Children’s Hospital at Vanderbilt are recognized again this year by U.S. News & World Report’s Best Hospitals as among the nation’s best with 18 nationally ranked specialties. Vanderbilt University Medical Center is world renowned because of the innovation, work ethic and collegiality of its employees. From our health care advances to our compassionate care, Vanderbilt owes its accomplishments and reputation to staff and faculty who bring skill and drive and innovation to the medical center day after day. World-leading academic departments and comprehensive centers of excellence pursue scientific discoveries and transformational educational and clinical advances across the entire spectrum of health and disease.As t...he largest employer in middle Tennessee, we welcome those who are interested in ongoing development in a caring, culturally sensitive and professional atmosphere. Most of us spend so much of our lives at work, we want to be part of maintaining a workplace in which people support one another and encourage reaching for excellence. Many high-achieving employees stay at Vanderbilt because of the professional growth they experience and because of their appreciation of Vanderbilt’s benefits, public events and discussions, athletic opportunities, beautiful setting and, above all, sense of community and purpose.Vanderbilt and its employees share a set of mutual expectations that have been created with productivity, legality, fairness and safety always in mind. We believe that our investment in training and compensating employees multiplies in value when we enable individuals to deliver their best performance for the benefit of us all.