Spec, Clinical Document Sr.
About The Position
Job Summary Conducts thorough analysis encompassing clinical review and assessment of patient records focusing on the documentation of the clinical condition and the care provided. Ensures that level of patient services provided is accurately and completely documented. Develops, communicates and implements solutions/programs to address problem areas identified through quality studies or claim denials working directly with physicians and other health care professionals. Essential Functions Works for the promotion of proper and ethical documentation and coding/billing activities, thus improving the organization’s level of accurate reimbursement. Conducts in-depth analysis of documentation of clinical care rendered in inpatient and outpatient settings. Uses critical analysis to determine appropriate DRG or coding assignment, appropriate setting, medical necessity, coverage of experimental services, and clinically related visits. Ensures that services are provided in accordance with state and federal regulations, organizational policy and accreditation/compliance requirements. Prepares detailed clinical summaries and/or other clinical documentation as necessary for role. Analyzes current practices in the areas of patient care, documentation and coding/billing, utilizing observation and data/statistical analysis to identify areas of opportunity. Develops and communicates recommended solutions/programs to address problem areas to physicians and other health care professionals. Communicates study or other findings and trains physicians and other healthcare professionals as required in current data and healthcare trends as it relates to appropriate clinical documentation and evidenced-based medicine. Utilizing project management skills, identifies project scope, project requirements, decision points, timelines, and resource requirements for planning, prioritization, implementation, and evaluation of complex, multifaceted quality and patient safety decision support projects and programs. Aids in the continuous monitoring of data for quality, cost effectiveness and efficiency. Engages in process and quality improvement activities. Engages in continuous study of the entire professional field, including best practices, to maintain the professional competence, knowledge, and skills necessary for the satisfactory performance of all assigned responsibilities. Completes required continuous training and education, including department specific requirements. Ensures that required documentation for activities within areas of responsibility is performed in an accurate and timely manner.
Requirements
- Bachelor's degree nursing, Health Related Field or Business Administration
- 3 years of relevant experience
- Clinical Role Required 1 of 3 required
- LIC-Registered Nurse (RN) - STATE_MI State of Michigan Upon Hire required Or
- LIC-Nurse Practitioner (NP) - STATE_MI State of Michigan Upon Hire required Or
- LIC-Physician Assistant - STATE_MI State of Michigan Upon Hire required
Nice To Haves
- Master's Degree Health Related Field
- Clinical Documentation Review CRT-Clinical Documentation Specialist, Certified (CCDS) - CCAP
Responsibilities
- Conducts thorough analysis encompassing clinical review and assessment of patient records focusing on the documentation of the clinical condition and the care provided.
- Ensures that level of patient services provided is accurately and completely documented.
- Develops, communicates and implements solutions/programs to address problem areas identified through quality studies or claim denials working directly with physicians and other health care professionals.
- Works for the promotion of proper and ethical documentation and coding/billing activities, thus improving the organization’s level of accurate reimbursement.
- Conducts in-depth analysis of documentation of clinical care rendered in inpatient and outpatient settings.
- Uses critical analysis to determine appropriate DRG or coding assignment, appropriate setting, medical necessity, coverage of experimental services, and clinically related visits.
- Ensures that services are provided in accordance with state and federal regulations, organizational policy and accreditation/compliance requirements.
- Prepares detailed clinical summaries and/or other clinical documentation as necessary for role.
- Analyzes current practices in the areas of patient care, documentation and coding/billing, utilizing observation and data/statistical analysis to identify areas of opportunity.
- Develops and communicates recommended solutions/programs to address problem areas to physicians and other health care professionals.
- Communicates study or other findings and trains physicians and other healthcare professionals as required in current data and healthcare trends as it relates to appropriate clinical documentation and evidenced-based medicine.
- Utilizing project management skills, identifies project scope, project requirements, decision points, timelines, and resource requirements for planning, prioritization, implementation, and evaluation of complex, multifaceted quality and patient safety decision support projects and programs.
- Aids in the continuous monitoring of data for quality, cost effectiveness and efficiency.
- Engages in process and quality improvement activities.
- Engages in continuous study of the entire professional field, including best practices, to maintain the professional competence, knowledge, and skills necessary for the satisfactory performance of all assigned responsibilities.
- Completes required continuous training and education, including department specific requirements.
- Ensures that required documentation for activities within areas of responsibility is performed in an accurate and timely manner.
Benefits
- Comprehensive benefits package to meet your financial, health, and work/life balance goals.
- Learn more here .
- 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
- Eligibility for benefits is determined by employment type and status
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
5,001-10,000 employees
