"Clinical Documentation Spec"

This key role is instrumental in improving the quality and completeness of provider-based clinical documentation within inpatient medical records. The CDIS will ensure the accurate representation of a patient's clinical status, affecting key metrics such as Present on Admission (POA), Severity of Illness (SOI), and Risk of Mortality (ROM) scores, while also influencing hospital reimbursement and the level of services provided. Collaboration with physicians and other clinical staff is essential to ensure comprehensive documentation that supports correct coding assignments at discharge. Additionally, the role involves creating and implementing an educational plan targeted at providers, emphasizing the principles of precise and complete documentation and its impact on SOI, ROM, and Length of Stay (LOS).

• Perform initial reviews of inpatient Pediatrics records to identify opportunities for clinical documentation improvement, impacting metrics such as DRG assignment, PSI, HAC, SOI, ROM, POA, and Risk O:E, as well as risk adjustment and accurate code assignment for billing.
• Conduct subsequent/follow-up reviews.
• Utilize CDI software to determine appropriate DRG, SOI, ROM, risk, and POA assignment.
• Evaluate clinical documentation, including signs, symptoms, lab results, diagnostic information, and treatment plans, to identify improvement opportunities, and engage in clarification with providers.
• Initiate communication with clinicians through the formal query process.
• Prepare case-specific documentation examples and PowerPoint presentations for clinical treatment teams and departments, relating to documentation and the Electronic Health Record (EHR).
• Develop and conduct ongoing education programs for new staff, CDI specialists, physicians, and nursing personnel.
• Adhere to the Health Information Management (HIM) Coding-CDI Query Policy and the Query Escalation Policy and follow standards of practice for quality and productivity.
• Demonstrate proficiency in abstracting and data entry into all CDI-related databases.
• Participate in and understand the Michigan Medicine annual SMART goal/evaluation process and CORE values.
• Demonstrate initiative by continuously expanding knowledge and skills.
• Engage in department/unit activities, including staff meetings, in-services, workgroups, and trial groups.
• Involvement in third-party audit denials and appeal processes by reviewing denials and submitting supporting documentation/evidence for defense.
• Perform other duties as assigned to maintain departmental efficiency.

Minimum Qualifications:

• An Associate's degree in health information technology, registration with the American Health Information Management Association as a Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA), and/or certification as a Registered Nurse (RN), or a 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.
• Adherence to the Michigan Medicine remote work agreement.