RN Clinical Documentation Specialist

GENERAL 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 DUTIES:

1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

6. Partners with HIM and Revenue Cycle professionals in third party payer DRG audits and appeals.

7. 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.

This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described.

STANDARD REQUIREMENTS:

1. Supports the Mission, Value and Vision of Beaumont Health (BH). Demonstrates personal commitment through active involvement in the performance improvement process.

2. Exhibits excellent customer service skills and behaviors toward internal and external customers and co-workers. Promotes positive public relations with patients/residents, family members, guests, and others.

3. Supports and adheres to all Beaumont Health’s customer service, service excellence, and performance standards. Supports and participates with all required compliance standards that may be department specific and/or identified by the organizations including in-service training, acceptable attendance, uniform and dress code.

4. Adheres to HIPAA requirements and maintains confidentiality of all data, including patient/resident, employee and operations information.

5. Supports and participates in a collaborative team oriented environment – cooperates and works together with all co-workers, plans and completes job duties, uses appropriate communications in sensitive and emotional situations and follows up as appropriate regarding reported complaints, problems and concerns.

6. Supports, cooperates with and demonstrates safe work practices and attitudes, follows safety rules – including universal precautions - reports and prevents/corrects unsafe conditions and behaviors, and participates in organizational and departmental safety programs.

7. Completes all required compliance standards that may be department specific and/or identified by the organization.

8. Maintains current licensure, registration and/or certification, as applicable, at all times.

STANDARD QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

A. Education/Training:

· Registered Nurse with Bachelor’s degree highly desirable and or MD with CCDS or CDIP highly recommended when eligible.

B. Work Experience:

· Minimum 3 years nursing experience required in an acute inpatient hospital setting.

C. Certification, Licensure, Registration:

· Current Registered Nurse (RN) license in State of Michigan/ MD-Medical Degree.

D. Other Qualifications:

· Requires effective verbal and written communication skills. Requires organizational skills with the ability to prioritize competing tasks. Must be able to establish credibility and integrity. Must be computer literate. Possess the ability and willingness to accept autonomy with responsibility, and commitment to collaborative practice.

WORKING CONDITIONS:

A. Physical Requirements:

· Strength: Position requires incumbent to infrequently perform physical activities requiring ability to push/pull objects up to 20 pounds and occasionally lift objects of up to 30 pounds.

· Manual Dexterity: Position requires incumbent to frequently perform simple motor skills such as answering a telephone, frequently perform simple and moderately difficult manipulative skills such as writing and typing.

· Coordination: Position requires incumbent to frequently perform gross body coordination such as walking, filing, retrieving manuals, frequently performing tasks which require eye-hand coordination such as keyboard skills.

· Mobility: Position requires incumbent to frequently perform mobility skills such as walking, standing, sitting and occasionally perform prolonged sitting.

· Visual Discrimination: Position requires incumbent to frequently see objects far away such as locating a client company and to discriminate colors in industrial signs; occasionally to see objects closely in reading faces or dials.

· Hearing: Position requires incumbent to constantly be able to hear normal sounds with some background of noise and to distinguish sounds as voice patterns in telephone conversations with clients.

Mental Requirements:

· Concentration: Position requires incumbent to constantly be able to concentrate on details with moderate amounts of interruptions such as staff requests, new projects, financial analysis and strategy, proposal preparation.

· Attention Span: Position require incumbent to attend to task/functions constantly for periods up to 60 minutes in length and frequently attend to task/functions constantly for periods exceeding 60 minutes in length such as complicated reports.

· Conceptualization: Position requires incumbent to frequently be able to understand and relate to specific ideas, concepts and theories.

· Memory: Position require incumbent to constantly remember task/assignments given to self and others over both short and long periods of time.

B. Environmental Conditions:

· Position requires incumbent to be exposed to a variety of substances within the home office environment, corporate facilities and other sites such as electro-magnetic radiations as in VDT’s and occasionally to dust.

Beaumont 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.