Facilitates complete and accurate clinical documentation by concurrently and retrospectively analyzing medical records and interacting with clinicians and medical record technicians to assure proper DRG assignment for appropriate reimbursement and data quality. Provides daily clinical evaluation of the medical record documentation, lab results, diagnostic information and treatment plans to support the appropriate clinical severity is captured for the level of service rendered. |
Requires completion of either an Associate level (RHIt) or Bachelor’s level (RHIA) Degree from an accredited Health Information Technology program or requires successful completion of a Registered Nurse program from an accredited school.
Requires demonstrated proficiency in inpatient coding experience in an acute care setting, equivalent of two years’ experience as a documentation specialist with formal training in human anatomy and/or physiology, medical terminology and disease processes or a minimum of two years’ recent clinical acute care inpatient experience with demonstrated working knowledge of inpatient coding processes, including Medicare rules, regulations and coding practices as well as commercial insurance and managed care rules.
Requires current Clinical Documentation Specialist certification or ability to obtain certification within two years' of placement. RN only - Requires a current and unrestricted registered nurse licensure in the State of Michigan.