Address
Form of workGENERAL SUMMARY
The Documentation Specialist RN facilitates accurate and timely clinical documentation in the medical record to capture severity of illness through collaboration with clinicians, providers, coding professionals, and nursing staff to support the coding process and appropriate DRG assignment. The Specialist RN uses the Code of Ethics for Nurses with Interpretive Statements to guide leadership and practice.
ESSENTIAL DUTIES AND RESPONSIBILITIES
OTHER DUTIES AND RESPONSIBILITIES
Provide education to providers and appropriate staff related to Certified Data Management Professionals(CDMP) principles and documentation improvement.
Timely follow up on all cases especially those with clinical documentation clarification.
Participate in monthly Task Force and Staff Meetings.
Manage multiple priorities. Accurate input of data into CDMP Trak®.
Weekly impact review of all cases with clarifications via CDMP Trak®.
All other duties as assigned.
CERTIFICATIONS AND LICENSURE
NSC - Nursing Specialty Certification Preferred
CCDS-Certified Documentation Specialist preferred within 3 years of hire.
RN - Registered Nurse Required
Current Registered Nurse license in the state of Michigan required.
REQUIRED EDUCATION
Associates Degree
Bachelor's degree in nursing at time of hire or transfer to position preferred.
**Associates prepared staff must obtain bachelor's degree in nursing by 1/1/2025.
EXPERIENCE, TRAINING AND SKILLS
Knowledge of nursing practices and procedures as normally acquired through 3 years' experience working in a Medical Center or similar setting.
Organizational, analytical, writing, and interpersonal skills.
Dependable, self-directed with excellent time management skills.
Critical thinking, problem-solving and deductive reasoning skills.
Minimum of 5 years of clinical experience -preferably critical care or strong Med/Surg background.
Knowledge of Pathophysiology and Disease Process.
Basic Computer skills - familiarity with Windows based software programs.
Knowledge of Medicare Part A. Familiar with Medicare Part B.
Knowledge of regulatory environment.
Understand and support CDMP® documentation strategies (upon completion of training).
Must follow MyMichigan Health blood borne pathogen and TB testing as required.
MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft® Windows.
An employee may be required to participate in further learning opportunities offered by MyMichigan Health.
PHYSICAL/MENTAL REQUIREMENTS AND TYPICAL WORKING CONDITIONS
Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death. Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position. Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description. Overall vision and hearing is necessary with or without assisted device(s). Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching. Some exposure to blood borne pathogens and other potentially infectious material. Must follow MyMichigan Health blood borne pathogen and TB testing as required. Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake. Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis. Physical Demand Level: Light. Must be able to occasionally (0-33% of the workday) lift or carry 11-20 lbs., frequently (34-66% of the workday) 10 lbs. and or Walk/Stand/Push/Pull of Arm/Leg controls.
The Documentation Specialist RN facilitates accurate and timely clinical documentation in the medical record to capture severity of illness through collaboration with clinicians, providers, coding professionals, and nursing staff to support the coding process and appropriate DRG assignment. The Specialist RN uses the Code of Ethics for Nurses with Interpretive Statements to guide leadership and practice.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- (25%)* Extensive record review utilizing JATA CDMP GUIDE software and documentation strategies to identify opportunities for documentation improvement.
- (25%)* Formulation of credible clinical clarifications to capture severity of illness to improve documentation of principle diagnosis, co-morbidities, and present on admission indicators.
- (25%)* Communication with providers, coding professional, and other staff using appropriate written and verbal communication skills to facilitate complete and accurate clinical documentation.
- (25%)* Work collaboratively with the coding professionals to ensure diagnosis codes/Diagnosis Related Group (DRG) accurately reflects the severity of illness and intensity of service provided to the patient while in our care.
OTHER DUTIES AND RESPONSIBILITIES
Provide education to providers and appropriate staff related to Certified Data Management Professionals(CDMP) principles and documentation improvement.
Timely follow up on all cases especially those with clinical documentation clarification.
Participate in monthly Task Force and Staff Meetings.
Manage multiple priorities. Accurate input of data into CDMP Trak®.
Weekly impact review of all cases with clarifications via CDMP Trak®.
All other duties as assigned.
CERTIFICATIONS AND LICENSURE
NSC - Nursing Specialty Certification Preferred
CCDS-Certified Documentation Specialist preferred within 3 years of hire.
RN - Registered Nurse Required
Current Registered Nurse license in the state of Michigan required.
REQUIRED EDUCATION
Associates Degree
Bachelor's degree in nursing at time of hire or transfer to position preferred.
**Associates prepared staff must obtain bachelor's degree in nursing by 1/1/2025.
EXPERIENCE, TRAINING AND SKILLS
Knowledge of nursing practices and procedures as normally acquired through 3 years' experience working in a Medical Center or similar setting.
Organizational, analytical, writing, and interpersonal skills.
Dependable, self-directed with excellent time management skills.
Critical thinking, problem-solving and deductive reasoning skills.
Minimum of 5 years of clinical experience -preferably critical care or strong Med/Surg background.
Knowledge of Pathophysiology and Disease Process.
Basic Computer skills - familiarity with Windows based software programs.
Knowledge of Medicare Part A. Familiar with Medicare Part B.
Knowledge of regulatory environment.
Understand and support CDMP® documentation strategies (upon completion of training).
Must follow MyMichigan Health blood borne pathogen and TB testing as required.
MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft® Windows.
An employee may be required to participate in further learning opportunities offered by MyMichigan Health.
PHYSICAL/MENTAL REQUIREMENTS AND TYPICAL WORKING CONDITIONS
Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death. Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position. Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description. Overall vision and hearing is necessary with or without assisted device(s). Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching. Some exposure to blood borne pathogens and other potentially infectious material. Must follow MyMichigan Health blood borne pathogen and TB testing as required. Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake. Overall dexterity is required including handling, reaching, grasping, fingering and feeling. May require repetition of these movements on a regular to frequent basis. Physical Demand Level: Light. Must be able to occasionally (0-33% of the workday) lift or carry 11-20 lbs., frequently (34-66% of the workday) 10 lbs. and or Walk/Stand/Push/Pull of Arm/Leg controls.
