Clinical Documentation Integrity Specialist - Full Time - 40 Hours - Days

Clinical Documentation Specialist

The Clinical Documentation Specialist (CDS) uses clinical, coding, and Clinical Documentation Integrity (CDI) knowledge and experience to improve the quality and integrity of documentation in the medical record. Identifies factors influencing the complexity of a patient's diagnosis and treatment plan. Serves as a CDI resource and works collaboratively with physicians, advanced practice providers, nursing, and ancillary services. Champions for advancement of the Henry Ford Health CDI program.

The Clinical Documentation Specialist (CDS) will:

• Review clinical documentation and diagnostic results in the electronic medical record (paper record during downtime) for patients within 48 hours of admission to ensure that signs, symptoms, diagnoses, and response to treatment are accurately documented and the medical record reflects the patient's severity of illness, risk of mortality, and resource consumption.
• Use clinical experience and knowledge of ICD-10-CM Coding Guidelines to identify opportunities to clarify documentation.
• Formulate compliant queries and adhere to approved process for query resolution.
• Collaborate with coding on retrospective reviews and queries.
• Perform reconciliation reviews to ensure query impact is captured and recorded correctly.
• Review CDI/Coding DRG mismatches and follow approved process for resolution.
• Conduct follow-up reviews to assess for accuracy and completeness of new documentation and identify new query opportunities.
• Collaborate with Quality teams to ensure documentation supports compliance with quality pathways and initiatives.
• Recognize educational opportunities and provide feedback to the education team.
• Understand and value the importance of data quality and integrity.
• Strive to establish and strengthen interdepartmental relationships and efficiencies.
• Maintain knowledge of new and existing coding rules and guidelines, DRG reimbursement, and documentation requirements.
• Answer provider questions regarding level of documentation detail for accurate, complete coding of diagnostic entries.
• Educate providers on the significance of appropriate documentation to support clinical acuity of care, i.e., quality audits, etc.
• Collaborate with coding staff to answer clinically based questions related to assignment of ICD-10-CM codes.
• Recommend opportunities for improvement to workflow and processes when identified.
• Additional duties as assigned.

Education/Experience Required:

• Registered Nurse (RN), BSN preferred, OR Certified Nurse Practitioner (CNP) or Physician Assistant (PA-C), OR International Medical Graduate.
• Demonstrated clinical competence as evidenced by 3-5 years clinical experience in one of the above roles in an acute care setting, preferably critical care.
• Basic PC knowledge required.
• Knowledge of ICD-10-CM Coding Guidelines.
• Knowledge of revenue cycle process preferred.
• Knowledge of health care fiscal management goals and strategies preferred, including, but not limited to trends and issues in health care reimbursement.

Certifications/Licensures Required:

• Current Registered Nurse (RN) license, OR Current Certified Nurse Practitioner (CNP) or Physician Assistant (PA-C) license, OR Current Educational Commission for Foreign Medical Graduates (ECFMG) credentials.