Clinical Documentation Improvement Specialist

Are you a detail-oriented individual with a passion for healthcare? Do you have experience in clinical documentation and a desire to improve patient outcomes? If so, we have a rewarding opportunity for you as a Clinical Documentation Improvement Specialist at Universal Health Services.In this role, you will play a crucial role in ensuring accurate and comprehensive documentation of patient care, which directly impacts the quality of care provided to our patients. We are seeking a driven and motivated individual with a strong understanding of medical terminology and coding guidelines, as well as excellent communication and analytical skills.If you are looking for a challenging yet fulfilling career in the healthcare industry, we encourage you to apply for this position and join our dedicated team of professionals at Universal Health Services.

1. Review and analyze patient medical records to identify areas for improvement in clinical documentation.
2. Collaborate with healthcare providers to clarify and obtain missing or incomplete documentation, ensuring accuracy and completeness of patient information.
3. Educate and train healthcare providers on proper documentation guidelines and procedures to improve overall quality of patient care.
4. Perform concurrent and retrospective reviews of medical records to ensure compliance with regulatory and coding guidelines.
5. Generate reports and provide feedback to healthcare providers and management on areas for improvement and progress made.
6. Utilize clinical knowledge and coding expertise to accurately assign diagnosis and procedure codes for reimbursement purposes.
7. Stay updated on changes in regulations and guidelines related to clinical documentation and coding, and implement necessary changes in processes.
8. Identify and communicate potential compliance issues and work with the compliance team to address them promptly.
9. Collaborate with other departments, such as coding and billing, to ensure accurate and timely submission of claims.
10. Maintain confidentiality and adhere to ethical standards in handling patient information.
11. Serve as a resource for healthcare providers and other staff regarding clinical documentation and coding questions.
12. Participate in quality improvement initiatives and contribute to the development of policies and procedures related to clinical documentation.
13. Attend meetings and trainings as required to stay updated on industry trends and best practices.
14. Provide support and guidance to new hires and assist with their training and development in clinical documentation and coding.
15. Maintain accurate and organized records of all documentation and activities related to clinical documentation improvement.

According to JobzMall, the average salary range for a Clinical Documentation Improvement Specialist in San Antonio, TX, USA is $58,000 - $80,000 per year. This can vary depending on factors such as experience, education, and specific job duties.

Universal Health Services, Inc. (UHS) is one of the largest and most respected providers of hospital and healthcare services in the nation with more than 90,000 employees dedicated to improving people’s lives and transforming the delivery of healthcare. Through its subsidiaries, the company operates 26 Acute Care hospitals, 328 Behavioral Health inpatient facilities, and 42 outpatient facilities and ambulatory care centers in 37 states in the U.S., Washington, D.C., Puerto Rico and the United Kingdom. UHS also offers health insurance plans through Prominence Health Plan, and manages a network of physicians through Independence Physician Management.