Clinical Documentation Specialist

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Role Overview

Conducts thorough analysis of inpatient medical records for clinical review and assessment of the documented clinical condition and care provided. Works with coding to ensure the DRG assigned is accurately and completely represented in documentation for system reimbursement. Collaborates with physicians and other healthcare professionals to address areas of opportunity identified through encounter data or claim denials.

Essential Functions

• Works for the promotion of proper and ethical documentation and coding / billing activities, thus improving the organization's level of accurate reimbursement. Conducts in-depth analysis of documentation of clinical care rendered in inpatient settings. Uses critical analysis to determine appropriate DRG or coding assignment, appropriate setting, medical necessity, coverage of experimental services, and clinically related visits. Ensures that services are provided in accordance with state and federal regulations, organizational policy and accreditation / compliance requirements.
• Prepares detailed clinical summaries and / or other clinical documentation as necessary for role.
• Analyzes current practices in the areas of patient care, documentation, and coding / billing, utilizing observation and data / statistical analysis to identify areas of opportunity.
• Develops and communicates recommended solutions / programs to address problem areas to physicians and other healthcare professionals. Communicates study or other findings and trains physicians and other healthcare professionals as required in current data and healthcare trends as it relates to appropriate clinical documentation and evidence-based medicine.
• Utilizing project management skills, identifies project scope, project requirements, decision points, timelines, and resource requirements for planning, prioritization, implementation, and evaluation of complex, multifaceted quality and patient safety decision support projects and programs.
• Aids in the continuous monitoring of data for quality, cost effectiveness and efficiency. Engages in process and quality improvement activities.
• Engages in continuous study of the entire professional field, including best practices, to maintain the professional competence, knowledge, and skills necessary for the satisfactory performance of all assigned responsibilities. Completes required continuous training and education, including department specific requirements.

Required Qualifications

Preferred Qualifications

About Corewell Health

As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement – to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.

Benefits

Location and Employment Details

Primary Location : SITE - Zeeland Hospital - 8333 Felch - Zeeland

Department : CDI Clinical Documentation Integrity Shared Services

Employment Type : Full time

Shift : Day (United States of America)

Weekly Scheduled Hours : 40

Hours of Work : 8 : 00 a.m. - 5 : 0 0 p.m.

Days Worked : Monday - Friday

Safety & Inclusion

Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy or sincerely held religious belief.

Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

An interconnected, collaborative culture where all are encouraged to bring their whole selves to work is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence to our inclusion resource groups, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

You may request assistance in completing the application process by calling 616.486.7447.

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