You haven't searched anything yet.
BASIC FUNCTION AND RESPONSIBILITY
To facilitate appropriate clinical documentation of inpatient medical records including the capture of diagnoses and procedures that impact present on admission (POA), severity of illness (SOI), risk of mortality (ROM) scores, hospital reimbursement and quality of patient care. Work collaboratively with physicians and other clinical staff to obtain complete documentation to allow for the correct code assignments by the coding staff at discharge. Develop and implement an education plan to communicate the principles and importance of accurate and complete documentation. Serve as a resource of documentation requirements and components of documentation within the electronic health record (EHR).
CHARACTERISTIC DUTIES AND RESPONSIBILITIES
OPERATIONS
Perform initial and follow-up reviews of inpatient records within 24-48 hours of admission to clinically evaluate the opportunity to query the clinician for additional diagnoses and/ or procedures that impact SOI, ROM, POA and hospital reimbursement.
Utilize the 3M/MiChart system to determine appropriate DRG, ICD-10 codes, SOI, ROM, and POA assignment
Evaluate clinical documentation such as signs, symptoms, lab results, diagnostic information and treatment plans to determine documentation improvement opportunities and appropriately query providers.
Initiate communication with clinicians through the formal query process or during face-to-face discussions when there is missing, ambiguous, or conflicting documentation to ensure timely and accurate documentation at the point of care.
Abstract all required information in MiChart in a timely manner to assure accurate reporting of metrics.
Review all death and hospice cases to assure that all documentation is captured that will impact hospital reimbursement, POA, SOI and ROM scores.
Facilitate change processes required to capture needed documentation, such as redesign or enhancement of EHR data capture functionality and/or template redesign.
Identify documentation trends to be shared with the clinical service and the Medical Director of CDI to allow for clinician education.
Provide on-going education to all clinical treatment teams as it relates to documentation and the EHR.
Prepare case-specific documentation examples and PowerPoint presentations to be given to clinical treatment teams and departments.
Maintains currency with work processes, tools, and clinical and administrative applications necessary to perform job functions
Participate in and demonstrate an understanding of the Michigan Quality System/Continuous Quality Improvement and applies Lean Thinking concepts in daily work
Demonstrate initiative by continuous expansion of knowledge and skills
Participate in department/unit activities including, but not limited to, staff meetings and in-services
Perform other duties as assigned in order to maintain the efficiency of the department
CUSTOMER SERVICE
Demonstrates excellent customer service skills in working with clinicians and functions as a liaison for Health Information Management
Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally. Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.
ICD-10 coding knowledge with a strong understanding of the AHA Official ICD-10 Coding Guidelines and how to apply them.
Clinical knowledge with the ability to review documentation and determine what documentation is needed to provide accurate DRG, POA, SOI, and ROM scores.
Excellent communication skills to enable effective outcomes with the diverse complex clinical care teams.
Write appropriate queries to the clinical care team in accordance with the AHIMA Query Policy.
Provide support to clinicians on making addendums and SmartTexts and SmartPhrases in MiChart.
Attention to Detail with thoroughness and accuracy when accomplishing a task.
Possess proactive, strategic, innovating and out-of-the-box thinking.
University of Michigan Health System is a service organization committed to values. We put our values into action each day with smiles, energy, enthusiasm and a commitment to always doing our best. We understand that in every interaction, we represent our entire organization in the care we give, the attention we pay and the courtesies we extend to both internal and external customers. We value respect, compassion, trust, integrity, efficiency and leadership and will expect nothing less.
Our values are demonstrated daily through our commitment to:
Patients and Families First
Accountability for Outcomes
Respect for Individuals
Teamwork
Never-ending Improvement
Empowerment
Responsibility for Cost Effectiveness
Service to the Community
Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings. Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.
Job openings are posted for a minimum of seven calendar days. The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled anytime after the minimum posting period has ended.
The University of Michigan is an equal opportunity/affirmative action employer.
247804
Clinical Documentation Specialist (CDS)
Clinical Documentation Spec
Michigan Medicine - Ann Arbor
Ann Arbor, MI
Full-Time
Regular
Exempt
Exec Vp Med Affairs
MM Rev Cycle (PTO)
4/17/2024 - 5/17/2024
Healthcare Admin & Support
Full Time
Colleges & Universities
$67k-84k (estimate)
04/23/2024
05/17/2024
umich.edu
ANN ARBOR, MI
15,000 - 50,000
1817
CAROL SENNEFF
$5B - $10B
Colleges & Universities
The mission of the University of Michigan is to serve the people of Michigan and the world through preeminence in creating, communicating, preserving and applying knowledge, art, and academic values, and in developing leaders and citizens who will challenge the present and enrich the future.
The job skills required for Clinical Documentation Specialist (CDS) include Health Information Management, Initiative, Clinical Documentation, Customer Service, Analysis, Patient Care, etc. Having related job skills and expertise will give you an advantage when applying to be a Clinical Documentation Specialist (CDS). That makes you unique and can impact how much salary you can get paid. Below are job openings related to skills required by Clinical Documentation Specialist (CDS). Select any job title you are interested in and start to search job requirements.
The following is the career advancement route for Clinical Documentation Specialist (CDS) positions, which can be used as a reference in future career path planning. As a Clinical Documentation Specialist (CDS), it can be promoted into senior positions as a Tumor Registrar that are expected to handle more key tasks, people in this role will get a higher salary paid than an ordinary Clinical Documentation Specialist (CDS). You can explore the career advancement for a Clinical Documentation Specialist (CDS) below and select your interested title to get hiring information.
If you are interested in becoming a Clinical Documentation Specialist, you need to understand the job requirements and the detailed related responsibilities. Of course, a good educational background and an applicable major will also help in job hunting. Below are some tips on how to become a Clinical Documentation Specialist for your reference.
Step 1: Understand the job description and responsibilities of an Accountant.
Quotes from people on Clinical Documentation Specialist job description and responsibilities
Finally, a good clinical documentation specialist must be able to maintain patient confidentiality.
02/19/2022: Sioux City, IA
Clinical Documentation Specialist analyzing medical information to assist healthcare providers.
02/18/2022: Nashua, NH
A clinical documentation specialist, also called a medical coder or billing specialist, oversees all types of health care documents.
02/05/2022: Waco, TX
At the same time, clinical documentation excellence programs should advance the quality, accuracy, and completeness of clinical documentation.
04/02/2022: Atlantic City, NJ
Clinical Documentation Specialist that are structured to be effective and efficient can provide the solutions needed to achieve accurate clinical documentation that contributes to precise health care data that’s required for value-based payment methodolo
02/20/2022: Carson City, NV
Step 2: Knowing the best tips for becoming an Accountant can help you explore the needs of the position and prepare for the job-related knowledge well ahead of time.
Career tips from people on Clinical Documentation Specialist jobs
Ensuring that there us proper documentation where needed
04/10/2022: Asheville, NC
Always strive for point-of-service documentation.
02/21/2022: Altoona, PA
Clinical documentation specialists gather and process these documents.
03/07/2022: Ventura, CA
Documentation specialists work with hospitals and alongside healthcare providers.
01/22/2022: Burlington, VT
Set up documentation shortcuts.
03/16/2022: Clarksville, TN
Step 3: View the best colleges and universities for Clinical Documentation Specialist.