Job Description

The Clinical Documentation Specialist (CDS) is a licensed, registered nurse who collaborates extensively with physicians, nursing staff, and other patient caregivers to ensure an accurate reflection of the patient’s acuity, diagnosis, and treatment rendered and a commensurate reimbursement. The CDS facilitates modifications to clinical documentation primarily while the patient is still under treatment or after discharge, but prior to submission of the hospital claim. This position works closely with the Coders to capture the correct ICD-10 codes and DRG assignment reflective of the patient’s visit and abides by the ICD-10 Official Coding Guidelines as well as the AHIMA and ACDIS compliant physician query ethics. The CDS position supports timely, accurate and complete documentation of clinical information used for measuring and reporting physician and facility outcomes including but not limited to Patient Safety Indicators, Hospital Acquired Conditions and Hierarchal Condition Categories. Communicates daily with physician and clinical staff, to request documentation clarification or clinical validation and to provide documentation education. May participate in performance improvement and education development teams related to strengthening documentation integrity and clinical workflow. This is a Munson Healthcare position which requires working remotely for all system hospitals where the CDI program is implemented, or a special project is requested.

Qualifications

ENTRY REQUIREMENTS

Bachelor of Science in Nursing and currently licensed as a Registered Nurse in the State of Michigan are required. Consideration will be given to licensed RNs who are enrolled in a bachelor’s nursing program and agree to complete the program within 5 years of hire.

A minimum three years’ experience in acute inpatient care nursing is required.

Experience in Critical Care or Med-Surg. is highly desirable.

In-depth knowledge of prospective payment, DRG and APC grouping, and ICD-10-CM and CPT classification systems is preferred.

Must be able to review and interpret clinical medical record information as it applies to coding and abstracting processes.

Experience in case management, utilization review or clinical documentation analysis preferred

Certified Clinical Documentation Specialist (CCDS) certification or eligibility highly desirable.

Additional Information

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Munson Healthcare requires all employees be vaccinated or have lab confirmed immunity for Measles, Mumps, Rubella and Varicella. MHC also requires all employees to receive a flu vaccine during the flu season in the year that they are hired and annually thereafter, or receive an approved medical or religious exemption.