Clinical Documentation Specialist I FT Days

Trane Technologies • Detroit, MI

3d • Onsite

About The Position

Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation.
Facilitates necessary documentation in the medical record through extensive interaction with physicians, nursing staff, other patient caregivers, and collaboration with HIM coding staff to ensure the most appropriate reimbursement is achieved for the level of service rendered to all patients.
Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and DMC pay for performance diagnosis specific quality outcomes.
Oversees clinical documentation patterns and trends to identify areas of improvement for the pay for performance measures.
Educates all members of the patient care team regarding clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and pay for performance documentation requirements on an on-going basis.
Develops and conducts on-going Performance Documentation education for new staff including case managers, coders, physicians, residents, nursing and allied health professionals.
Compiles, analyzes and evaluates quality and clinical data collected as part of an integrated system-wide program of clinical improvement and documentation requirements.

Requirements

• Graduate from an accredited school of Nursing.
• 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.
• OR Associate's degree in applied sciences or related field with emphasis in healthcare.
• Three years of inpatient coding experience.
• OR Graduate from an accredited medical school, either foreign or domestic, preferably with a CCDS (Certified Clinical Documentation Specialist) credential and must have a minimum of one year experience working as a Clinical Documentation Specialist in an acute care hospital.

Nice To Haves

• Bachelors degree in Nursing preferred.
• Critical care nursing experience preferred.
• Bachelors degree in a related area preferred.
• Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist).
• Clinical Documentation Specialist experience in an acute care hospital preferred.

Responsibilities

• Improving the overall quality and completeness of clinical documentation.
• Facilitates necessary documentation in the medical record through extensive interaction with physicians, nursing staff, other patient caregivers, and collaboration with HIM coding staff
• Ensuring the accuracy and completeness of clinical information used for measuring and reporting physician and DMC pay for performance diagnosis specific quality outcomes.
• Overseeing clinical documentation patterns and trends to identify areas of improvement for the pay for performance measures.
• Educating all members of the patient care team regarding clinical documentation needs, changes to clinical documentation guidelines, coding and reimbursement issues, and pay for performance documentation requirements on an on-going basis.
• Developing and conducting on-going Performance Documentation education for new staff including case managers, coders, physicians, residents, nursing and allied health professionals.
• Compiling, analyzing and evaluating quality and clinical data collected as part of an integrated system-wide program of clinical improvement and documentation requirements.

What This Job Offers

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