Description
Under the direction of Director Corporate Clinical Documentation Improvement (CDI) and Regional Director CDI, the Clinical Documentation Improvement Team Lead is responsible for assisting in the management, coordination, and day-to-day operations and workflow of the CDI team. The goal of the Clinical Documentation Improvement Team is to ensure accurate, complete, and compliant documentation. The objective is to ensure quality outcomes and revenue integrity through coordination, collaboration, and communication with related disciplines in order to address and integrate opportunities for documentation improvement.
- This position is remote with travel to McLaren subsidiaries and leadership meetings as required.
Essential Functions and Responsibilities:
Ability to perform CDI reviews as needed. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and hospital pay for performance diagnosis specific quality outcomes. Assigns Working DRGs & ICD10 CM/PCS codes.
Ability to perform second level reviews, as needed. Utilizes 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 to resolve issues.
Assess education opportunity with CDI staff and physicians. Communicates with and 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. Present education to physician and clinical documentation team as needed (or requested).
Conducts additional chart reviews for:
Perform chart reviews for Clinical Validation, Patient Safety Indicators (PSI), Mortalities, Hospital Acquired Conditions (HAC) and Payer denials.
Facilitates appropriate clinical documentation, to ensure that the severity of illness, risk of mortality and level of services provided are accurately reflected in the health record. Assists in overall quality, timeliness and completeness of the quality health record to ensure appropriate data, provider communication, and quality outcomes. Serves as a resource for appropriate clinical documentation.
Qualifications
Required:
BSN
Current Registered Nurse License in the State of practice
Minimum 7 years of acute hospital care experience
Minimum 5 years of clinical documentation improvement experience
Certified Clinical Documentation Specialist (CCDS) and maintenance of continuing education requirements
Member with the Association of Clinical Documentation Improvement Specialists (ACDIS)
Preferred:
Nicotine Testing - To provide a safe, healthy environment for our patients, employees and visitors, as of February 1, 2013 McLaren no longer hires individuals who use nicotine and will conduct nicotine testing during the pre-employment process. If the test is positive the offer will be rescinded. Individuals who test positive may re-apply for employment after six months.
Equal Opportunity Employer of Minorities/Females/Disabled/Veterans
Job: Nurse
Primary Location: Michigan-Flint Location-McLaren Reg Med Center
Organization McLaren Health Care Corp
Employee Status Regular
Shift Day Job
Job Type Standard
Schedule Full-time
Job Posting May 20, 2019, 2:42:20 PM
Req ID: 19005265