Clinical Documentation Improvement Specialist Registered Nurse

About the role

The Clinical Documentation Improvement Specialist Registered Nurse position at McLaren Health Care involves ensuring the accuracy and completeness of clinical information used for measuring and reporting physician and hospital outcomes. This role requires performing daily chart reviews to clarify documentation with the health record, assigning working DRGs & ICD10 CM/PCS codes, facilitating necessary documentation through interactions with various healthcare professionals, and educating the patient care team on clinical documentation needs.

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.

Requirements

• Current Registered Nurse License in the State of practice
• Minimum 5 years of acute hospital care experience
• Certified Clinical Documentation Specialist (CCDS), or obtain certification when eligible as defined by the Association of Clinical Documentation Improvement Specialists – ACDIS, and maintenance of continuing education requirements
• Member (or obtain within 1 year of service) with the Association of Clinical Documentation Improvement Specialists (ACDIS)
• 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.

Qualifications

Qualified candidates must meet the following qualifications:

• Current Registered Nurse License in the State of practice
• Minimum 5 years of acute hospital care experience
• Certified Clinical Documentation Specialist (CCDS), or obtain certification when eligible as defined by the Association of Clinical Documentation Improvement Specialists – ACDIS, and maintenance of continuing education requirements
• Member (or obtain within 1 year of service) with the Association of Clinical Documentation Improvement Specialists (ACDIS)
• 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.

Skills

Skills required for this role include:

• Ability to work independently and as part of a team
• Strong communication skills, both verbal and written
• Attention to detail and ability to manage multiple tasks simultaneously
• Proficiency in Microsoft Office Suite
• Understanding of healthcare policies and regulations

Benefits

McLaren Health Care offers competitive benefits including health insurance, retirement plans, paid time off, and professional development opportunities.

Pay

Competitive salary based on experience and qualifications.

Schedule

Full-time position with flexible scheduling to accommodate patient care needs.

Equal Opportunity Employer

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