Documentation Specialist

Job Summary 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. Essential Functions 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. Qualifications Required 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 Preferred Bachelor’s degree in nursing CRT-Clinical Documentation Specialist, Certified (CCDS CRT-Documentation Improvement Practitioner, Certified (CDIP) #J-18808-Ljbffr Corewell Health