Clinical Documentation Specialist - PRN

Position Overview

• Department: Clinical Documentation Integrity
• Schedule: PRN (0500-2100 flexible) minimium 8hrs every 2 weeks
• Work Location: UAB St Vincent's Birminging - Remote

Preferred Qualifications

• CCDS or CDIP certification preferred
• Minimum of three years of CDI experience

Job Description

Facilitate improvement in overall quality, completeness and accuracy of medical record documentation.

• Complete admission reviews and assign a working Diagnosis Related Group. Ensure the working DRG and other information are entered in the Clinical Documentation Improvement database.
• Initiate and maintain extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.
• Collaborate with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge.
• Maintain accurate records of review activities, ensuring reports and outcomes of CDI efforts are valid.

Qualifications

Licensure / Certification / Registration

• One or more of the following required:
• Certified Coding Specialist (CCS) credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
• Certified Professional Coder (CPC) credentialed from the American Academy of Professional Coders (AAPC) obtained prior to hire date or job transfer date.
• Clinical Documentation Prof. credentialed from the Association of Clinical Documentation Improvement Specialists obtained prior to hire date or job transfer date.
• Licensed Registered Nurse credentialed from the Alabama Board of Nursing obtained prior to hire date or job transfer date.
• Reg Health Info Admnstr credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.
• Reg Health Info Tech credentialed from the American Health Information Management Association (AHIMA) obtained prior to hire date or job transfer date.

Education

• High School diploma equivalency with 2 years of cumulative experience OR Associate's

degree/Bachelor's degree OR 4 years of applicable cumulative job specific experience required.

Why Work at UAB Medicine

We are UAB Medicine, Alabama’s largest and most comprehensive health system, recognized nationally for delivering world-class patient care, pioneering research, and cutting-edge medical education. We proudly serve more than 1.2 million patients each year – from every county in Alabama, all 50 states, and many countries around the world. Our network spans numerous hospitals, emergency departments, many other sites of care, and a team of over 2,000 physicians. Our key facilities include UAB Hospital – ranked the No. 1 hospital in Alabama by U.S. News & World Report and home to the state’s first ACS-verified Level I adult trauma center and only Magnet-designated hospital – along with UAB Hospital-Callahan Eye and five UAB St. Vincent’s hospitals serving central Alabama.

UAB Medicine offers careers across a wide range of practice environments, from our internationally renowned academic medical center and award-winning community hospitals to our primary and specialty care clinics across the state. Whether you’re seeking the fast-paced learning environment of a tertiary care setting or the close-knit environment of a community facility, there’s a place for you on our team where you can become part of a mission-driven organization committed to delivering life-changing care. With nearly every medical specialty represented and unlimited opportunities for growth, you’ll find the right fit for your skills and career goals. We care for you by offering comprehensive, industry-leading benefit packages to support the individual preferences and circumstances of our diverse staff.