Documentation Specialist Jobs

About The Position

Requirements

• Current Registered Nurse License in the State of practice
• Minimum 5 years of acute hospital care experience
• Certified Clinical Documentation Specialist (CCDS), or obtain certification when eligible as defined by the Association of Clinical Documentation Improvement Specialists – ACDIS, and maintenance of continuing education requirements
• Member (or obtain within 1 year of service) with the Association of Clinical Documentation Improvement Specialists (ACDIS)

Nice To Haves

• CDIP certification
• Experience with CDI Software Tools (i.e. 3M 360, JATA, ChartWise, other)
• Knowledge of coding/documentation and billing regulations related to commercial insurance, Medicaid and Medicare. (i.e., APR-DRG, MS-DRG, Medicare, Medicaid & Managed Care)
• Experience in Utilization Management/Case Management, Critical Care, and patient outcomes/quality management preferred. Inpatient coding experience desired.
• Nicotine Testing - To provide a safe, healthy environment for our patients, employees and visitors, as of February 1, 2013 McLaren no longer hires individuals who use nicotine and will conduct nicotine testing during the pre-employment process. If the test is positive the offer will be rescinded. Individuals who test positive may re-apply for employment after six months.

Responsibilities

• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
• Performs daily chart reviews seeking opportunity to clarify (query) documentation with the health record to capture accurate, complete and compliant documentation. Assigns Working DRGs & ICD10 CM/PCS codes.
• 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.
• 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.