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As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, integrity, quality and trust that are integral to our mission. EO/AA
This position is responsible for improving the overall quality and completeness of clinical documentation by communicating with and providing education to physicians, case managers, coders and other health team members to facilitate comprehensive medical record documentation that reflects clinical treatment, decisions, and diagnoses for patients. This position may be required to access and administer medications within their scope of practice and according to state law.
Corporate Overview: The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for our academic research, quality standards and overall patient experience. Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes.
ResponsibilitiesEssential Functions- Ensures documentation meets quality standards and an accurate reflection of the patient's status is entered in the medical record.
- Provides education to staff and physicians on the importance of the Clinical Documentation Improvement Program (CDIP).
- Facilitates modifications to clinical documentation through extensive concurrent interactions with physicians, nursing staff and coding to support that appropriate reimbursement and clinical severity is captured.
- Supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and hospital outcomes.
- Assists the assigned coder with concurrently reviewing the medical records of inpatients and subsequently discusses documentation opportunities with the various physician teams.
- Acts as consultant to coders when additional information or documentation is needed to assign the correct DRG.
- Participates in assigned hospital, and unit and departmental committees.
- At the discretion of department operational and patient care needs, this position is required to work rotating schedules, which may include variable hours, weekends, nights, and holidays to meet the staffing and patient care demands of a 24/7 complex health system. Regular, reliable, and punctual attendance during assigned shifts is considered an essential function of the role.
- Demonstrated ability to perform the essential functions as outlined above.
- Demonstrated availability to work variable and rotating shifts, including nights, weekends, and holidays, in a 24/7 patient care environment.
- Ability to provide care to the population served.
- Demonstrated knowledge of the principles of life span growth and development and the ability to assess data regarding the patient's status and provide care as described in the department's policies and procedures manual.
- Demonstrated human relations and effective communication skills.
- Demonstrated ability to collaborate with coders, physician teams and hospital staff.
- Demonstrated knowledge of state and federal regulations.
- Ability to identify and monitor trends and opportunities for documentation improvement.
- Five years of clinical and critical nursing experience.
- Bachelor's degree in Nursing or equivalency.
- Current license to practice as a Registered Nurse in the State of Utah, or obtain one within 90 days of hire under the interstate compact if switching residency to State of Utah. Must maintain current Interstate Compact (multi-state) license if residency is not being changed to Utah.
* Additional license requirements as determined by the hiring department.
Qualifications (Preferred)Preferred- Knowledge of ICD-9 and DRG.
Employee must be able to meet the following requirements with or without an accommodation.
- This is a sedentary position in an office setting that may exert up to 10 pounds and may lift, carry, push,pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions.
Skills Required
- Five years of clinical and critical nursing experience
- Bachelor's degree in Nursing or equivalent
- Current Registered Nurse license in Utah, or eligibility to obtain one within 90 days under the interstate compact
- Ability to work variable and rotating shifts, including nights, weekends, and holidays
- Knowledge of ICD-9 and DRG
University of Utah Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about University of Utah and has not been reviewed or approved by University of Utah.
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Retirement Support — Employer-funded retirement contributions on both the academic campus and U of U Health are notably strong, with automatic contributions and additional voluntary savings options. This emphasis makes long-term financial benefits a distinctive part of the total compensation offering.
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Healthcare Strength — Multiple medical plan choices, robust mental-health support through the Employee Assistance Program, and wellness programs create a comprehensive health offering. Network options and wellness incentives further enhance coverage quality.
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Parental & Family Support — Paid parental leave policies provide options for fully paid periods or extended partial-pay leave for staff, with parallel provisions at U of U Health. Separate frameworks for faculty include modified duties and leave arrangements during family transitions.
University of Utah Insights
What We Do
The University of Utah, located in Salt Lake City in the foothills of the Wasatch Mountains, is the flagship institution of higher learning in Utah. Founded in 1850, it serves over 31,000 students from across the U.S. and the world. With over 72 major subjects at the undergraduate level and more than 90 major fields of study at the graduate level, including law and medicine, the university prepares students to live and compete in the global workplace. Known for its proximity to seven world-class ski resorts within 40 minutes of campus, the U encourages an active, holistic lifestyle, innovation and collaborative thinking to engage students, faculty and business leaders. The University of Utah became a member of the PAC-12 conference in July 2011. Technology and Commercialization The University of Utah is tops in the country for creating start-up companies from university research, according to a ranking by the Association of University Technology Managers (AUTM). See http://unews.utah.edu/news_releases/u-of-utah-no-1-for-startups for more information. Forbes magazine’s recent ranking of the “Best States for Business” pointed to “an educated labor force” as a big reason Utah came in at number one. The U supplies many of the employees for companies that keep expanding their operations in Utah, such as Goldman Sachs, Adobe, Omniture, Oracle, Ebay and many others. http://pac12info.utah.edu/commercialization-of-innovation/ Healthcare University of Utah Health Care recently ranked first in the nation in a prestigious national study. The University Health System Consortium’s 2010 Quality and Accountability Study compared 98 of the nation’s top academic medical centers and ranked them based on core quality measures, patient safety indicators, mortality rates, re-admission rates, and patient satisfaction scores. See more about University of Utah Health Care at http://healthcare.utah.edu/index.php
