Clinical Documentation Specialist

About This Role

This role is instrumental in improving the quality and completeness of clinical documentation within inpatient medical records, ensuring accurate representation of a patient's clinical status and influencing key metrics. The specialist will collaborate with physicians and other clinical staff to support correct coding assignments and develop educational programs for providers.

Responsibilities

• Perform initial reviews of inpatient Pediatrics records to identify opportunities for clinical documentation improvement
• Conduct subsequent/follow-up reviews
• Utilize CDI software to determine appropriate DRG, SOI, ROM, risk, and POA assignment
• Evaluate clinical documentation and engage in clarification with providers
• Initiate communication with clinicians through the formal query process
• Prepare case-specific documentation examples and presentations for clinical treatment teams
• Develop and conduct ongoing education programs for staff, physicians, and nursing personnel
• Adhere to HIM Coding-CDI Query Policy and the Query Escalation Policy
• Demonstrate proficiency in abstracting and data entry into all CDI-related databases
• Involvement in third-party audit denials and appeal processes

Requirements

• Associate's degree or Bachelor's degree with specific certifications
• Registration with the American Health Information Management Association as RHIT or RHIA, and/or certification as RN, NP, PA, or MD
• Three years of experience in an inpatient setting (coding or clinical roles)
• Adherence to the Michigan Medicine remote work agreement

Qualifications

• Associate's degree in health information technology, or Bachelor's degree and certification in Nursing, Nurse Practitioner (NP), Physician Assistant (PA), or Medical Doctor (MD)
• Three years of experience in an inpatient setting, either in coding or clinical roles.

Skills

* Required skills

Certifications