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Universal Health Services

Manages hospitals and behavioral health facilities

Lead Clinical Documentation Coordinator

Clinical Support & Patient AdministrationPosted on Nov 9
Full-timeAiken, SC, USANo salary listedIn-person

About the Job

Requirements

  • Graduate of a nursing program.
  • Have a minimum of 5 years of recent clinical experience in an acute care setting.
  • Have 3–5 years of experience with inpatient coding and DRG guidelines.
  • Be able to work independently in a time-oriented environment.
  • Have excellent written and verbal communication skills.
  • Have knowledge of age-specific needs and elements of disease processes and related procedures.
  • Have broad-based clinical knowledge and understanding of pathology and physiology of disease processes.
  • Have computer literacy.
  • Be a registered nurse with a current South Carolina license.

Responsibilities

  • Manage the operations of the Clinical Documentation Improvement (CDI) program.
  • Manage departmental staff, including day-to-day supervision, employee relations, and staff development.
  • Function as the super-user and trainer for the CDI program and all application software used by staff to code and assign working MS-DRG, APR-DRG, severity of illness (SOI), and risk of mortality (ROM).
  • Serve as the lead educational resource for internal customers on CDI program effectiveness and requirements related to compliant documentation for DRG revenue assurance, compliance, and quality outcomes.
  • Oversee CDIS audits to ensure compliant and effective queries.
  • Provide influence and guidance while managing the CDI team.
  • Identify areas for improvement by analyzing and interpreting process and operational reports, financial and compliance reports, and quality ratings reports.
  • Assist with operational matters, including scheduling and coverage of reviews, query development and auditing, physician education, program monitoring, and process refinement to clarify documentation in records.
  • Coordinate follow-up on unanswered queries during the patient stay, as needed, to obtain prompt responses to open queries.
  • Serve as a resource to physicians and administration regarding the appropriateness of inpatient DRG assignment.
  • Collaborate with the CDI team and healthcare professionals to facilitate medical-record documentation supporting patient severity of illness and risk of mortality, using appropriate querying tools to capture needed documentation.
  • Perform other duties as assigned or required.

Desired Qualifications

  • A Bachelor of Science in Nursing (BSN) is preferred.
  • Critical care or medical/surgical experience is preferred.
  • Working knowledge of the Medicare reimbursement system and coding guidelines is preferred.
  • RHIA, RHIT, or CCS credential is preferred.

About the Company

Universal Health Services

Manages hospitals and behavioral health facilities

Universal Health Services operates a network of acute care hospitals, behavioral health facilities, and ambulatory centers across the United States. It generates its services by acquiring and managing healthcare facilities, then integrating them under centralized operating practices to deliver patient care. The company’s offering is the management and provision of hospital and behavioral health services, with a focus on standardized clinical operations, economies of scale, and nationwide coverage. What sets UHS apart is its long history of growth through acquisitions, its size and scale in both acute and behavioral health markets, and its ability to integrate new facilities while maintaining consistent care quality. Its goal is to provide high-quality healthcare across a broad network, improve patient outcomes, and sustain long-term value for shareholders by expanding access and efficiency in hospital and behavioral health services.

Company size
10,001+
Company stage
IPO
Headquarters
Upper Merion Township, Pennsylvania
Founded
1978

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