Clinical Documentation Improvement Specialist Registered Nurse

McLaren Health Care; Lansing (MI); On-site; USD 70,000 - 90,000; Full time

Job summary

McLaren Health Care in Michigan is seeking a Clinical Documentation Improvement (CDI) Specialist to enhance the quality and completeness of medical record documentation. The role focuses on capturing accurate, complete, and compliant documentation to support outcomes and revenue integrity through collaboration with clinicians and coding staff.

Responsibilities include daily chart reviews to identify documentation gaps, performing queries, educating care teams on guidelines and

Qualifications

• Current RN license in the state of practice.
• Minimum 5 years of acute hospital care experience.
• CDIP certification preferred.
• Inpatient coding experience preferred.

Responsibilities

• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
• Performs daily chart reviews seeking opportunity to clarify (query) documentation to capture accurate, complete and compliant documentation.
• Educates all members of the patient care team regarding clinical documentation needs, changes to guidelines, coding and reimbursement issues, and pay for performance documentation requirements.
• Uses interpersonal skills to discuss clinical documentation issues and work with coders, physicians, nursing staff, and other professionals to resolve issues.
• Facilitates the Documentation Improvement Initiative and directs others toward objectives that contribute to program success.
• Articulates the program to physician and other health care professionals to educate and teach documentation requirements for MS-DRG reimbursement and quality measures.
• Performs other related duties as required and directed.

Skills

Clinical documentation

Interpersonal communication

Medical record review

Query writing

Education

Registered Nurse (RN) license

Tools

3M 360

JATA

ChartWise

Job description

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:

• Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes.
• 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.
• 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.
• 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.
• 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)

Additional Information

• Schedule: Full-time
• Requisition ID: 26011150
• Daily Work Times: 8:00am-4:30pm
• Hours Per Pay Period: 80
• On Call: No
• Weekends: No