Clinical Documentation Improvement Specialist Registered Nurse
McLaren Health Care
1 day ago
Full-time
On-site
Grand Blanc, Michigan, United States
Registered Nurse
Position Summary: The Clinical Documentation Improvement (CDI) Specialist is responsible for facilitating improvement of the overall quality and completeness of medical record documentation. CDI Specialist role is to facilitate quality outcomes and revenue integrity through capture of accurate, complete, and compliant documentation through coordination, collaboration, and communication with related disciplines to address and integrate opportunities for documentation improvement and provider education.
Essential Functions and Responsibilities:
1. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
2. 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.
3. 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.
4. 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.
Uses interpersonal skills to discuss clinical documentation issues and work effectively with all levels of internal personnel such as coders, physicians, nursing and allied health professionals, and some external customers including third party payors to resolve issues.
Facilitates the processes associated with the Documentation Improvement Initiative, encourage a spirit of cooperation among clinicians, coders, physicians, etc., and direct others toward objectives that contribute to the success of the program.
Articulates the program to physician and other health care professionals in order to educate and teach clinical documentation requirements for both MS-DRG reimbursement and pay for performance quality measures.
8. Performs other related duties as required and directed.
Qualifications:
Required
· Current Registered Nurse License in the State of practice
· Minimum 5 years of acute hospital care experience
Preferred:
· 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.
· Certified Clinical Documentation Specialist (CCDS)
· Member with the Association of Clinical Documentation Improvement Specialists (ACDIS)
Essential Functions and Responsibilities:
1. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
2. 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.
3. 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.
4. 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.
Uses interpersonal skills to discuss clinical documentation issues and work effectively with all levels of internal personnel such as coders, physicians, nursing and allied health professionals, and some external customers including third party payors to resolve issues.
Facilitates the processes associated with the Documentation Improvement Initiative, encourage a spirit of cooperation among clinicians, coders, physicians, etc., and direct others toward objectives that contribute to the success of the program.
Articulates the program to physician and other health care professionals in order to educate and teach clinical documentation requirements for both MS-DRG reimbursement and pay for performance quality measures.
8. Performs other related duties as required and directed.
Qualifications:
Required
· Current Registered Nurse License in the State of practice
· Minimum 5 years of acute hospital care experience
Preferred:
· 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.
· Certified Clinical Documentation Specialist (CCDS)
· Member with the Association of Clinical Documentation Improvement Specialists (ACDIS)