Job Summary
Under general supervision and according to established policies and procedures, assists in planning, organizing, coordinating and implementing clinical documentation guidelines including coding practices, reviewing reimbursement, maintaining optimal quality care documentation as it relates to pay for performance initiatives for Detroit Market Adult Hospitals. Coordinates the work of assigned professional and technical personnel. Participates in clinical research projects and clinical case conferences and various staff competency and development programs.
1. Provides assistance in planning, organizing and implementing clinical documentation improvement practices as related to impact on accuracy and completeness of the medical record, quality of care, LOS/Excess Days, and CMI.
2. As a team leader, coordinates and delegates the work of assigned professional and technical personnel to achieved departmental/program objectives. Schedules, evaluates competency and work completion of assigned areas for professional and technical staff.
3. Provides facilitation of 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. Participates in patient care rounds and consults with health care providers to ensure most effective documentation.
4. Participates in the development of goals and objectives, workload reporting, budget development for specific service areas and monitoring of these objectives. Develops, secures approval of and implements policies and procedures specific to clinical documentation. Monitors and develops revisions to processes as necessary.
5. Assists in the planning and implementation, data collection, analysis and documentation of CDS' daily work activities.
6. Assists in planning monthly CDIS/hospital leadership meetings, including presentation of monthly CDIS statistics and scorecards. Follows-up on deficiencies in statistics.
7. Monitors procedures and processes to identify improvements, formulates recommendations, secures approvals, and facilitates implementation.
8. Assists in the selection, hiring, evaluation, discipline and/or discharge of assigned CDIS staff.
9. Performs other duties as assigned.
Qualifications:
Minimum Qualifications
1. Graduate from an accredited school of Nursing. Bachelor's degree in Nursing preferred. License to practice as a Registered Nurse in the State of Michigan. Three years of clinically well-rounded medical or surgical acute care nursing experience. Critical care nursing experience preferred. Two years of experience as a Clinical Documentation Specialist. Certified Clinical Documentation Specialist (CCDS) credentials preferred.
OR
Associate's degree in applied sciences or related field with emphasis in healthcare. Bachelor's degree in a related area preferred. Credentialed as a RHIA (Registered Health Information Administrator), RHIT (Registered Health Information Technician) or CCS (Certified Coding Specialist). Three years of inpatient coding experience. Two years of experience as a Clinical Documentation Specialist. Experience in an acute care hospital preferred.
OR
Graduate from an accredited medical school, either foreign or domestic, with a CCDS (Certified Clinical Documentation Specialist) credential. Two years of experience working as a Clinical Documentation Specialist in an acute care hospital.
2. Prior leadership experience such as precepting within the department and functioning as a departmental leader.
Skills Required
1. Clinical skills reflecting a thorough understanding of pharmacologic, sociologic and management principles necessary to understand the safe and effective utilization of medical resources by patients.
2. Analytical ability and comprehensive knowledge base to gather and interpret clinical documentation data, to identify discrepancies or issues, and to determine methods for ensuring compliance with clinical documentation policies and procedures. Ability to analyze data for patterns and trends.
3. Strong critical thinking skills and ability to integrate knowledge. Excellent observation, communication and decision making abilities. Ability to assess, evaluate and educate all members of the care team.
4. Ability to prioritize work, focus on completion of tasks and meet deadlines through strong organizational skills. Demonstrates motivation and is able to work as a focused, self-directed individual.
5. High-level communication skills both verbal and written. Ability to collaborate and use assertive 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 payers.
6. Strong presentation skills are necessary to articulate the program to physician and other health care professionals in order to educate and teach clinical documentation requirements for both DRG reimbursement and pay for performance quality measures.
7. Demonstrated leadership skills through professionalism as a team player in order to facilitate the processes associated with Clinical Documentation Improvement,, encourage a spirit of cooperation among clinicians, coders, physicians, etc., and direct others toward objectives that contribute to the success of the program.
8. Knowledge of clinical documentation guidelines, policies and procedures, and the requirements of third party payors most frequently seen with the DMC patient population.
9. Ability to cope with stressful situations, manage multiple and sometimes conflicting priorities simultaneously.
10. Ability to use computer systems; computer skills and knowledge of various software packages including database and spreadsheet programs.
Facility Description
DMC Harper University Hospital has distinguished itself in surgery and medicine and is known for its clinical expertise and innovative research. A specialty referral hospital, Harper has established Centers of Excellence in neurosciences, bariatric surgery, vascular services, multidisciplinary cardiovascular services, hypertension, stroke prevention and heart failure.
