Clinical Documentation Specialist

Job Summary 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) - Upon Hire CRT-Documentation Improvement Practitioner, Certified (CDIP) - Upon Hire How Corewell Health cares for you 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 Traditional and Roth retirement options with service contribution and match savings Eligibility for benefits is determined by employment type and status Primary Location SITE - Troy Hospital - 44201 Dequindre Rd - Troy Department Name Concurrent Clinical Assurance Program - Corporate Employment Type Full time Shift Day (United States of America) Weekly Scheduled Hours 40 Hours of Work 8:00 a.m. - 4:30 p.m. Days Worked Monday - Friday Weekend Frequency N/A Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief. Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category. An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team. You may request assistance in completing the application process by calling View phone number on click.appcast.io. People are at the heart of everything we do, and the inspiration for our legacy of outstanding outcomes, innovation, strong community partnerships, philanthropy and transparency. Corewell Health is a not-for-profit health system that provides health care and coverage with an exceptional team of 60,000+ dedicated people—including more than 11,500 physicians and advanced practice providers and more than 15,000 nurses providing care and services in 22 hospitals, 300+ outpatient locations and several post-acute facilities—and Priority Health, a provider-sponsored health plan serving more than 1.2 million members. Through experience and collaboration, we are reimagining a better, more equitable model of health and wellness. #J-18808-Ljbffr