Corewell Health
DocumentationSpecialist
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“Documentation Specialist at Corewell Health. Skills: clinical documentation, patient classification, DRG assignment, provider documentation. 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.”
What You'll Achieve.
highest integrity of the medical record; appropriate clinical severity is captured for the level of service rendered; complete and accurate coding for proper reimbursement
What They're Looking For.
Must Have
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
Nice to Have
Bachelor’s degree in nursing, CRT-Clinical Documentation Specialist, Certified (CCDS), CRT-Documentation Improvement Practitioner, Certified (CDIP)
What You'll Do.
Identifies factors influencing the complexity and severity of patient diagnoses
Works collaboratively with providers to ensure overall specificity
accuracy and completeness of clinical documentation to support the highest integrity of the medical record.
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
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.
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
presentations and providing documentation tips.
How You'll Work.
Team & Collaboration
Works collaboratively with providers; Communicates with providers and healthcare team members; Partners with HIM and Revenue Cycle professionals; Educates members of the healthcare team
Communication Scope
verbal or electronic query practices; presentations
Full Job Description
## 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 Sta
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