Beaumont Health System Clinical Documentation Spec in Royal Oak, Michigan
Clinical Documentation Spec Req #: 30113304 Category: Admin Support/Clerical Facility: Admin Bldg Med Info Services Department: Clinical Documentation Improve Schedule: Full time Shift: DaysHours: Core hrs: 5am-7pm Job Details:This position is at Beaumont Dearborn/Taylor/Trenton/WayneGENERAL 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 practices6. 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.STANDARD QUALIFICATIONSTo 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.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.Beaumont Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, , gender identity, orientation, age, status as a protected veteran, or status as a qualified individual with a disability.