Why UnityPoint Health? 

Commitment to our Team – We’re proud to be recognized as a Top 150 Place to Work in Healthcare by Becker's Healthcare several years in a row for our commitment to our team members. 

Culture – At UnityPoint Health, you matter. Come for a fulfilling career and experience a culture guided by uncompromising values and an unwavering belief in doing what's right for the people we serve. 

Benefits – Our competitive Total Rewards program offers benefits options that align with your needs and priorities, no matter what life stage you’re in. 

• Caring is what we do, and it starts with our team members: expect paid time off, parental leave, 401K matching and an employee recognition program as we support you both personally and professionally. 
• You can only give your best when you feel your best, and we help you live well with dental and health insurance, paid holidays, short and long-term disability and more. We even offer pet insurance for your four-legged family members to give you peace of mind. 
• We strive to make things easier and more personal in health care to set us apart from the rest, and you can experience that commitment through early access to earned wages with Daily Pay, a tuition reimbursement program designed to help you further your career and adoption assistance to help you grow your family in the way that works for you. 

Diversity, Equity and Inclusion Commitment – At UnityPoint Health, we honor the ways people are unique and embrace what brings us together. Our collective goal is to champion a culture of belonging where everyone feels valued and respected.  

Development – We believe equipping you with support and development opportunities is an essential part of delivering a remarkable employment experience. 

Community Involvement – Be an essential part of our core purpose—to improve the health of the people and communities we serve. 

Hear more from our team members about why UnityPoint Health is a great place to work at  https://dayinthelife.unitypoint.org 

We're seeking a Clinical Documentation Integrity Specialist (CDIS) RN to join our team! In this role, you'll be responsible for performing concurrent review of medical records to ensure complete and accurate clinical documentation to support severity of illness, risk of mortality for outcomes reporting, and for hospital reimbursement. The position requires a strong attention to detail and process orientation and an ability to think globally about documentation requirements in the medical records.  The CDS must communicate effectively in oral and written form to physicians and other clinicians to promote accurate and complete documentation during the patient’s course of care.  CDS supports the hospital’s overall compliance efforts designed to ensure the accuracy of diagnosis and procedural coding, Diagnosis Related Group (DRG) assignment, severity of illness (SOI), and expected risk of mortality (ROM).

This position is remote/work from home and must be within 60 miles of a UnityPoint health affiliate in IL, IA, or WI.

What You'll Do:

Operational:

• Conducts reviews of designated medical records to facilitate the creation of a health record that accurately represents the acuity of the patient’s illness and the resources used to treat the patient by ensuring provider documentation supports all applicable diagnosis codes.
• Ensures assignment of the working DRG is supported by diagnostic and procedural findings from the medical record. This will include the identification of secondary diagnosis that may result in Complications and Co-morbidities (CC) and/or Major Complications and Co-morbidities (MCC) assignment.
• Utilizes a compliant query process per guidelines and policies and follows each query through closure including complete documentation of ongoing follow up and communication.
• Maintains integrity and compliance of medical record reviews, clinical documentation integrity documentation, and queries.
• Efficiently and effectively utilizes UnityPoint Health’s selected CDI software and processes (i.e. CDI worksheet and workflow, physician query, query and DRG reconciliation processes).
• Meets the minimum productivity and quality assurance standards established by the CDI department.

Relationship Building/Collaboration:

• Collaborates with coding staff and leaders for improved knowledge and understanding of coding guidelines.
• Collaborates with physicians and/or other hospital staff to coordinate work and resolve issues.
• Collaborates with Clinical Documentation Integrity leaders to provide feedback and receive work direction.
• Collaborates with other hospital departments as needed and directed by CDI leaders.

What You'll Need:

Education:

• RN
• BSN or higher preferred 

Experience:

• At least 5 years of full-time adult acute care RN experience in med/surg, critical care, emergency or Utilization review required.
• Previous experience in clinical documentation improvement is preferred.
• Previous experience with chart review or chart auditing is preferred.
• Knowledge of ICD CM/PCS coding guidelines

License(s)/Certification(s):

• Registered Nurse licensure required

• Certified Clinical Documentation Specialist (CCDS) preferred

• Certified Documentation Improvement Practitioner (CDIP) preferred

Knowledge/Skills/Abilities:

• Excellent interpersonal and communication skills
• Knowledge of reimbursement systems, federal, state, and payer specific regulations and policies pertaining to documentation and coding
• Multicultural sensitivity
• Microsoft Office – basic computer skills
• Customer/patient focused
• Critical thinking skills using independent judgment in making decisions
• Action Planning
• Ability to work independently
• Highly motivated, self-starter who works effectively with minimum supervision
• Ability to organize work quickly and efficiently and be comfortable working against deadlines
• Maintain effective working relationships