Documentation Specialist

Corewell Health • Southfield, MI

3d • Onsite

About The Position

Identifies factors influencing the complexity and severity of patient diagnoses, and/or procedures. Works collaboratively with providers to ensure overall specificity, accuracy and completeness of clinical documentation to support the highest integrity of the medical record. Utilizes clinical expertise, clinical documentation improvement practices and facility specific tools for best practice and compliance with the mission and vision of the revenue cycle. Provides daily clinical evaluation of all documentation by the Medical Staff and healthcare team, lab results, diagnostic information and treatment plans to assure the appropriate clinical severity is captured for the level of service rendered. Reviews and makes recommendations for improvement to the overall quality, integrity and completeness of clinical documentation by utilizing knowledge of DRG-based payor issues, clinical documentation guidelines, policies and procedures. Guides, supports and sponsors the Clinical Documentation Improvement Program efforts. In partnership with Clinical Coders, ensures patient classification and DRG assignment are supported by provider documentation and in compliance with rules, regulations and guidelines. Communicates with providers and healthcare team members to clarify documentation necessary for complete and accurate coding for proper reimbursement via verbal or electronic query practices. Partners with HIM and Revenue Cycle professionals in third party payer DRG audits and appeals. Educates members of the healthcare team about clinical documentation guidelines, coding and quality measures via 1:1 rounding, unit rounds, presentations and providing documentation tips.

Requirements

• Required associate’s degree
• 3 years of relevant experience
• Nursing experience required in an acute inpatient hospital setting.
• LIC-Registered Nurse (RN) - STATE_MI State of Michigan Upon Hire
• LIC-Physician (MD) - STATE_MI State of Michigan Upon Hire

Nice To Haves

• Bachelor’s degree in nursing
• CRT-Clinical Documentation Specialist, Certified (CDCS)
• CRT-Documentation Improvement Practitioner, Certified (CDIP)

Responsibilities

• Provides daily clinical evaluation of all documentation by the Medical Staff and healthcare team, lab results, diagnostic information and treatment plans to assure the appropriate clinical severity is captured for the level of service rendered.
• Reviews and makes recommendations for improvement to the overall quality, integrity and completeness of clinical documentation by utilizing knowledge of DRG-based payor issues, clinical documentation guidelines, policies and procedures.
• Guides, supports and sponsors the Clinical Documentation Improvement Program efforts.
• In partnership with Clinical Coders, ensures patient classification and DRG assignment are supported by provider documentation and in compliance with rules, regulations and guidelines.
• Communicates with providers and healthcare team members to clarify documentation necessary for complete and accurate coding for proper reimbursement via verbal or electronic query practices.
• Partners with HIM and Revenue Cycle professionals in third party payer DRG audits and appeals.
• Educates members of the healthcare team about clinical documentation guidelines, coding and quality measures via 1:1 rounding, unit rounds, presentations and providing documentation tips.

Benefits

• Comprehensive benefits package to meet your financial, health, and work/life balance goals.
• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance, pet insurance
• Traditional and Roth retirement options with service contribution and match savings

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree