Title: Clinical Documentation Auditor Location: La Grange, IL, USA Job Description: Part time job requisition id R-0352626 Our promise to you: Joining UChicago Medicine AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. UChicago Medicine AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better. All the benefits and perks you need for you and your family: - Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance - Paid Time Off from Day One - 403-B Retirement Plan - 4 Weeks 100% Paid Parental Leave - Career Development - Whole Person Well-being Resources - Mental Health Resources and Support - Pet Benefits Schedule: Part time Shift: Day (United States of America) Address: 5101 WILLOW SPRINGS RD City: LA GRANGE State: Illinois Postal Code: 60525 Job Description: - Schedule: Part Time, 24 hours/week; flexible scheduling within standard business hours - Remote role but candidate must be local to area. Must be available for in-person meetings every other month and in-person training/education as needed Completes accurate and timely record reviews to ensure the integrity of documentation compliance. Inputs data accurately and concisely into CDI Software. Reviews concurrent and retrospective medical records for documentation compliance, including completeness and accuracy for SOI, ROM, and quality. Supports CDI documentation strategies and educates self and team members through monthly mandated education sessions and provided educational tools. Conducts quality audits, including deceased second-level reviews, focused disease process reviews, patient safety indicators, and CDI team audits. Collects, analyzes, and reports data to the CDI Leadership team. Recognizes opportunities for documentation improvement using strong critical-thinking skills. Uses critical thinking and sound judgment in decision-making, balancing quality considerations with regulatory compliance. Educates patient-care team members on documentation regulations and guidelines, including quarterly and annual compliance updates from Medicare. Initiates and formulates CDI severity worksheets and clinically credible clarifications for inpatients. Presents opportunities for improved documentation compliance to physicians, nurse practitioners, and other clinical team members. Transcribes documentation clarifications as appropriate for SOI, ROM, PSI, HCCs, and HACs. Other duties as assigned. Knowledge, Skills, and Abilities: • Excellent interpersonal skills including excellent verbal and written communication skills; proficient in and demonstrates excellent physician relations. [Required] • Able to organize and present information clearly and concisely. [Required] • Excellent computer and keyboarding skills; ability to use multiple software programs simultaneously; high degree of prioritization skills. [Required] • Ability to learn/develop and fine-tune the skills necessary to perform optimally as a Clinical Documentation Specialist. [Required] • Dependable, self-motivated, and pleasant. [Required] • Utilize and demonstrate excellent critical-thinking, problem-solving and deductive-reasoning skills. [Required] • Knowledge of pathophysiology, disease processes and treatments. [Required] • Strong ability to organize/triage work and manage multiple priorities at once. [Required] • Knowledge of quality guidelines. [Required] • Knowledge of clinical documentation requirements that identify clinical conditions or procedures. [Preferred] • Coding background. [Preferred] Education: • Associates [Required] • Master's [Preferred] Field of Study: • of Science in Nursing and 3 years of Clinical Documentation Integrity Specialist experience OR 4 years of recent Clinical Documentation Specialist experience • of Science in Nursing • or higher degree in a healthcare related field Work Experience: • 1+ of second level review CDIS experience • 4+ of recent clinical documentation specialist experience [Required] • 4+ acute care nursing experience with specific medical/surgical, intensive care, post-acute care unit, or emergency department experience [Required] • 5+ CDI experience Licenses and Certifications: • Certified Billing and Coding Specialist (CBCS) [Required) * Registered Nurse (RN) [Required] OR Physician Assistant (PA) [Required] OR Certified Registered Nurse Practitioner (CRNP) [Required] OR Advanced Practice Registered Nurse (APRN) [Required] OR Medical Doctor (MD) [Required] OR Doctor of Osteopathic Medicine (DO) [Required] OR Educational Commission for Foreign Medical Graduates (ECFMG) [Required] Pay Range: $71,588.85 - $133,150.39 This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

• Lead the development of high-quality regulatory and clinical documents • Oversee medical writing workstreams, ensuring deliverables meet quality and timeline expectations • Prepare and review clinical study reports, protocols, and regulatory documents for accuracy and clarity • Collaborate with cross-functional teams to gather and synthesize information for document development • Provide guidance on medical writing best practices and ensure adherence to regulatory requirements • Mentor and train junior medical writers, fostering a culture of excellence and professional growth • Stay current with industry trends and regulatory guidelines

Role Description The Clinical Documentation Improvement Specialist is responsible for improving overall quality and completeness of clinical documentation to ensure that the information in the medical record accurately reflects the patient's severity of illness, clinical needs, and utilization of resources. - This position is responsible for reviewing death medical records to ensure the severity of illness and risk of mortality has been captured at the highest level. - This position works with the providers of care to capture the clinical care in a code format for reimbursement and to ensure UAMS has the correct case mix. - Reviews all admission types to the hospital to ensure severity is captured and then educates the providers of care on admission types. Qualifications - Registered Nurse (RN) with current license plus 4 years inpatient clinical experience in Emergency, Critical Care, or Medical/Surgical area with experience in Quality, Case Management, Clinical Audit, or Data Abstraction OR Coding professional with CCS certification and 6 years of inpatient coding experience with documented education in anatomy/physiology and pharmacology. - CCDS is required within 6 months of hire. - Current CCDS (preferred). Requirements - Applies extensive clinical knowledge to read and analyze health record documentation, identifying all significant diagnoses, treatment, and procedures impacting acuity level and resources consumed throughout the current hospitalization. - Applies knowledge of disease processes, surgical procedures, UHDDS definitions, and the CMS/NCHS ICD-10 Official Coding Guidelines for Coding and Reporting to assign non-indexed terms to the appropriate class within the ICD-10 coding classification system. - Reviews all death medical records and works with Vizient calculator to ensure risk of mortality and severity of illness scores are correct. - Interacts directly with physicians, nursing staff, other patient caregivers, coding staff, and other members of the health care team to facilitate clarification of clinical documentation and transfer of knowledge related to accurate documentation, coding, and reimbursement practices. - Develops and facilitates education related to clinical documentation improvement, coding guidelines, and regulatory requirements to all members of the healthcare team through one-on-one communication and classroom or large group presentations throughout the year as assigned. - Performs other duties as assigned. Benefits - Health: Medical, Dental and Vision plans available for qualifying staff and family. - Holiday, Vacation and Sick Leave. - Education discount for staff and dependents (undergraduate only). - Retirement: Up to 10% matched contribution from UAMS. - Basic Life Insurance up to $50,000. - Career Training and Educational Opportunities. - Merchant Discounts. - Concierge prescription delivery on the main campus when using UAMS pharmacy. Company Description The University of Arkansas for Medical Sciences (UAMS) has a unique combination of education, research, and clinical programs that encourages and supports teamwork and diversity. We champion being a collaborative health care organization, focused on improving patient care and the lives of Arkansans.

• Responsible for improving overall quality and completeness of clinical documentation • Ensure that the information in the medical record accurately reflects the patient's severity of illness, clinical needs, and utilization of resources • Review death medical records to ensure the severity of illness and risk of mortality has been captured at the highest level • Work with the providers of care to capture the clinical care in a code format for reimbursement and to ensure UAMS has the correct case mix • Review all admission types to the hospital to ensure severity is captured and then educate the providers of care on admission types.