Clinical Documentation Improvement Specialist Registered Nurse

McLaren Health Care; Grand Blanc (MI); On-site; USD 90,000 - 110,000; Full time

Job summary

McLaren Health Care in Michigan seeks a Clinical Documentation Improvement Specialist Registered Nurse to drive documentation quality and revenue integrity across the network.

You will partner with physicians, nursing staff, and coding teams to query, educate, and implement CDI best practices, ensuring accurate MS-DRG reimbursement and compliance. Requires RN license and 5+ years acute care; CDI tools experience preferred; on-site, full-time.

Qualifications

• Current Registered Nurse License in the state of practice.
• Minimum 5 years of acute hospital care experience.
• Experience with CDI software tools (3M 360, JATA, ChartWise, other).
• Knowledge of coding/documentation and billing regulations for commercial insurance, Medicaid and Medicare (APR-DRG, MS-DRG).
• Experience in Utilization Management/Case Management, Critical Care, and patient outcomes/quality management preferred.
• Certified Clinical Documentation Specialist (CCDS) and AC DIS membership are a plus.

Responsibilities

• Ensure accuracy and completeness of clinical information used for outcomes and reporting.
• Perform daily chart reviews to query documentation and capture accurate reimbursement.
• Educate care teams on documentation needs, guidelines, and pay-for-performance requirements.
• Collaborate with physicians, nursing staff, coders, and HIM to resolve documentation issues.
• Direct others toward objectives that improve documentation and reimbursement quality.
• Articulate the CDI program to clinical staff and educate on MS-DRG and quality measures.

Skills

RN license

CDI software tools

coding & reimbursement knowledge

Utilization/Case management

ACDIS CCDS familiarity

Tools

3M 360

JATA

ChartWise

Job description

The McLaren system includes 12 hospitals across the state, ambulatory surgery centers, imaging centers, a 730-member employed primary and specialty care physician network, commercial and Medicaid HMOs covering more than 242,000 Michigan lives, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network, and a wholly owned medical malpractice insurance company. McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, a National Cancer Institute-designated comprehensive cancer center. McLaren has 20,000 full-, part-time and contracted employees and more than 93,000 network providers throughout Michigan.

Clinical Documentation Improvement Specialist 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:

• 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)

Additional Information

• Schedule: Full-time
• Requisition ID: 26011150
• Daily Work Times: 8:00am-4:30pm
• On Call: No

McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status, national origin, disability, genetic information, height or weight, protected veteran or other classification protected by law.

McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employmentwithout regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status,national origin, disability, genetic information, height or weight, protected veteran or other classificationprotected by law.