Clinical Documentation Specialist I FT Days

Trane Technologies • Detroit, MI

16d • Onsite

About The Position

Under limited direction and in accordance with clinical documentation guidelines and established policies and procedures, improves the overall quality and completeness of clinical documentation. The specialist facilitates necessary medical-record documentation through extensive interaction with physicians, nursing staff, and other patient caregivers, and collaboration with HIM coding staff, to support appropriate reimbursement for the level of service rendered.

The role ensures accurate and complete clinical information for measuring and reporting physician and DMC pay-for-performance diagnosis-specific quality outcomes. It monitors clinical documentation patterns and trends to identify areas for improvement, educates patient-care team members on documentation needs, guideline changes, coding and reimbursement issues, and pay-for-performance requirements, and develops and conducts ongoing documentation education for new staff. The specialist also compiles, analyzes, and evaluates quality and clinical data as part of an integrated system-wide clinical improvement and documentation program.

Requirements

• Graduate from an accredited school of Nursing and hold a license to practice as a Registered Nurse in the State of Michigan; three years of clinically well-rounded medical or surgical acute care nursing experience. Alternatively, an associate's degree in applied sciences or a related field with an emphasis in healthcare, a qualifying RHIA, RHIT, or CCS credential, and three years of inpatient coding experience.
• Alternatively, graduate from an accredited medical school, domestic or foreign, and have at least one year of experience as a Clinical Documentation Specialist in an acute care hospital.

Nice To Haves

• Bachelor's degree in Nursing preferred for the nursing pathway.
• Critical care nursing experience preferred.
• Bachelor's degree in a related area preferred for the health-information/coding pathway.
• Clinical Documentation Specialist experience in an acute care hospital preferred.
• A CCDS (Certified Clinical Documentation Specialist) credential is preferred for the medical-school pathway.

Responsibilities

• Improve the overall quality and completeness of clinical documentation.
• Facilitate necessary medical-record documentation through interaction with physicians, nursing staff, other patient caregivers, and HIM coding staff.
• Support appropriate reimbursement for the level of service rendered to patients.
• Ensure the accuracy and completeness of clinical information used to measure and report physician and DMC pay-for-performance diagnosis-specific quality outcomes.
• Monitor clinical documentation patterns and trends to identify improvement opportunities for pay-for-performance measures.
• Educate patient-care team members about clinical documentation needs, changes to guidelines, coding and reimbursement issues, and pay-for-performance documentation requirements.
• Develop and conduct ongoing performance documentation education for new staff, including case managers, coders, physicians, residents, nursing staff, and allied health professionals.
• Compile, analyze, and evaluate quality and clinical data collected as part of a system-wide clinical improvement and documentation program.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level