Job Description

This role is based out of UM Capital Region Medical Center

1. DOCUMENTATION: Facilitates initial assessment of the quality of clinical documentation for all types of patients. Reviews relevant sections of the record and develops a documentation improvement plan consistent with the clinical picture of each patient.
2. TEAMWORK: Engages in face-to-face time with physicians; describes what documentation is necessary for accurate coding; explains benefits of accurate/timely clinical documentation. Provides leadership and facilitates multidisciplinary discussions regarding documentation improvement. Assists in correcting knowledge deficits on part of physicians and other staff members. Assumes a leadership role in continual assessment of the quality of documentation and identifies opportunities for improvement. Organizes and participates in training and CDI program promotional activities for physicians and staff.

Qualifications

• 4 year / Bachelor’s Degree: Nursing (required)
• Master’s Degree (preferred)
• Registered Nurse Certified (required)
• RHIA, RHIT (preferred)
• 4 - 6 years Clinical Nursing, or Health Information Management experience (required)
• 6 - 9 years Clinical Nursing, or Health Information Management experience (preferred)
• Required Skills: Strong Verbal Communications Skills, Basic Computer skill

Additional Information

All your information will be kept confidential according to EEO guidelines.

Compensation:
Pay Range: $38.67 - $58.05
Other Compensation (if applicable):
Review the 2025-2026 UMMS Benefits Guide

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