Under limited direction and according to clinical documentation guidelines and established policies/procedures, responsible for improving the overall quality and completeness of clinical documentation. Facilitates 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. Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and DMC pay for performance diagnosis specific quality outcomes. Oversees clinical documentation patterns and trends to identify areas of improvement for the pay for performance measures. 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. Develops and conducts on-going Performance Documentation education for new staff including case managers, coders, physicians, residents, nursing and allied health professionals. Compiles, analyzes and evaluates quality and clinical data collected as part of an integrated system-wide program of clinical improvement and documentation requirements.
1. Graduate from an accredited school of Nursing. Bachelors 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. OR
2. Associate's degree in applied sciences or related field with emphasis in healthcare. Bachelors 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. 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 and minimum of one year experience working as a Clinical Documentation Specialist in an acute care hospital.
Primary Location: Detroit, Michigan
Facility: DMC Sinai-Grace Hospital
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 2105000281
About DMC Sinai-Grace Hospital
Tenet Healthcare Corporation (NYSE: THC) is a diversified healthcare services company headquartered in Dallas with 112,000 employees. Through an expansive care network that includes United Surgical Partners International, we operate 65 hospitals and approximately 510 other healthcare facilities, including surgical hospitals, ambulatory surgery centers, urgent care and imaging centers and other care sites and clinics. We also operate Conifer Health Solutions, which provides revenue cycle management and value-based care services to hospitals, health systems, physician practices, employers and other clients. Across the Tenet enterprise, we are united by our mission to deliver quality, compassionate care in the communities we serve.