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CLINICAL DOCUMENTATION SPECIALIST

MU Health Care
dental insurance, paid time off, tuition assistance
United States, Missouri, Columbia
1 Hospital Drive (Show on map)
Jun 06, 2025

Shift:Monday - Friday, 8am - 5pm
Department: Clinical Documentation Integrity - Available as Remote
Compensation:

* Base Pay Range: $56,596 - $89,419 per year, based on experience



ABOUT THE JOB

MU Health Care is actively seeking a Clinical Documentation Specialist who is passionate about the power of documentation in revolutionizing patient care. In this pivotal role, you'll champion impeccable ICD-9-CM coding, ensuring that our healthcare documentation practices set the industry standard. Your expertise in data analysis and trend identification will drive efficiency and precision in our documentation workflows. Collaborating closely with physicians and practitioners, you'll be the driving force behind our commitment to elevating the quality of patient records. If you're ready to make a significant impact through the art of documentation, join us in shaping the future of healthcare documentation and transforming patient outcomes.

ABOUT MU HEALTH CARE

At MU Health Care, we have an inspired, hard-working and collaborative environment driven by our mission to save and improve lives. We believe anything is possible and rally around solutions. We celebrate innovation and offer opportunities to be a part of something bigger - to have a voice and role in the work that is serving our community and changing the field of medicine.

Our academic health system - the only in mid-Missouri - is home to multiple hospitals, including the region's only Level 1 Trauma Center and region's only Children's Hospital as well as over 90 specialty clinics. Here, you can define your career among our many clinical and nonclinical positions - with growth, opportunity and support every step of the way.

Learn more about MU Health Care.

Learn more about living in mid-Missouri.

EMPLOYEE BENEFITS

* Health, vision and dental insurance coverage starting day one

* Generous paid leave and paid time off, including nine holidays

* Multiple retirement options, including 100% matching up to 8%and full vesting in three years

* Tuition assistance for employees (75%) and immediate family members (50%)

* Discounts on cell phone plans, rental cars, gyms, hotels and more

* See a comprehensive list of benefitshere.

DETAILED JOB DESCRIPTION

Gathers data, enters data, harvests from databases, compiles information, and prepares reports to facilitate efficient workloads, identifies trends/issues for corrective action.

Creates reports providing team productivity, physician intradepartmental feedback, project specific data, and identification of trends/issues with coding and documentation accuracy.

Interacts with patient care providers (physicians, APRN's, PA's, etc.) by means of in-services, rounding, clarification query requests and personal contacts to ensure quality documentation practices, documentation clarification, documentation policies/procedures and regulations.

Maintains knowledge of current and developing issues and trends in medical coding, and documentation, and outcomes registries.

Maintains knowledge and expertise in electronic software tools (IDX, Cerner, 3M, etc.).

Reviews and analyzes inpatient or outpatient medical records for quality documentation practices resulting in accurate and compliant queries as needed to assist in ICD-9 and ICD-10 coding assignments or outcomes registries.

Works collaboratively with coding staff for determining principal diagnoses, DRG, CPTs, and severity scorings.

Other duties as assigned, including special projects assigned by organizational leadership.

May complete unit/department specific duties and expectations as outlined in department documents.

KNOWLEDGE, SKILLS, & ABILITIES

Skill in interactive cross-departmental relationships.

Ability to communicate effectively orally, and in writing, and before audiences.

REQUIRED QUALIFICATIONS

Experience in documentation review, quality, ICD-10 coding, and Current Procedural Technology CPT's.

Respiratory Care Practitioner (RCP) or (RCP-T) licensure by the Missouri Respiratory Care board; OR

Missouri Board of Nursing RN, or Nurse Licensure Compact multi-state RN. When primary state of residency changes, compact state RNs must apply under new state of residency within thirty (30) days.

PREFERRED QUALIFICATIONS

Broad clinical expertise and direct contact with physicians.

Additional license/certification requirements as determined by the hiring department.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met with or without reasonable accommodation. The performance of these physical demands is an essential function of the job. The employee may be required ambulate, remain in a stationary position and position self to reach and/or move objects above the shoulders and below the knees. The employee may be required to move objects up to 10 lbs.



Equal Employment Opportunity

The University of Missouri is an Equal Opportunity Employer.

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