To facilitate appropriate clinical documentation of inpatient medical records including the capture of diagnoses and procedures that impact present on admission (POA), severity of illness (SOI), risk of mortality (ROM) scores, hospital reimbursement and quality of patient care. Work collaboratively with physicians and other clinical staff to obtain complete documentation to allow for the correct code assignments by the coding staff at discharge. Develop and implement an education plan to communicate the principles and importance of accurate and complete documentation. Serve as a resource of documentation requirements and components of documentation within the electronic health record (EHR).
- Perform initial and follow-up reviews of inpatient records within 24-48 hours of admission to clinically evaluate the opportunity to query the clinician for additional diagnoses and/ or procedures that impact SOI, ROM, POA and hospital reimbursement.
- Utilize the 3M/MiChart system to determine appropriate DRG, ICD-10 codes, SOI, ROM, and POA assignment
- Evaluate clinical documentation such as signs, symptoms, lab results, diagnostic information and treatment plans to determine documentation improvement opportunities and appropriately query providers.
- Initiate communication with clinicians through the formal query process or during face-to-face discussions when there is missing, ambiguous, or conflicting documentation to ensure timely and accurate documentation at the point of care.
- Abstract all required information in MiChart in a timely manner to assure accurate reporting of metrics.
- Review all death and hospice cases to assure that all documentation is captured that will impact hospital reimbursement, POA, SOI and ROM scores.
- Facilitate change processes required to capture needed documentation, such as redesign or enhancement of EHR data capture functionality and/or template redesign.
- Identify documentation trends to be shared with the clinical service and the HIM physician advisor to allow for clinician education.
- Provide on-going education to all clinical treatment teams as it relates to documentation and the EHR.
- Prepare case specific documentation examples and power point presentations to be given to clinical treatment teams and departments.
- Maintains currency with work processes, tools, and clinical and administrative applications necessary to perform job functions
- Participate in and demonstrate an understanding of the Michigan Quality System/Continuous Quality Improvement and applies Lean Thinking concepts in daily work
- Demonstrate initiative by continuous expansion of knowledge and skills
- Participate in department/unit activities including, but not limited to, staff meetings and in-services
- Perform other duties as assigned in order to maintain the efficiency of the department
- Demonstrates excellent customer service skills in working with clinicians and functions as a liaison for Health Information Management
- ICD-10 coding knowledge with a strong understanding of the AHA Official ICD-10 Coding Guidelines and how to apply them.
- Clinical knowledge with the ability to review documentation and determine what documentation is needed to provide accurate DRG, POA, SOI, and ROM scores.
- Excellent communication skills to enable effective outcomes with the diverse complex clinical care teams.
- Write appropriate queries to the clinical care team in accordance with the AHIMA Query Policy.
- Provide support to clinicians on making addendums and SmartTexts and SmartPhrases in MiChart.
- Attention to Detail with thoroughness and accuracy when accomplishing a task.
- Possess proactive, strategic, innovating and out-of-the-box thinking.
General supervision is received from the CDI Manager
- An Associate’s Degree in Health Information Technology and registration with the American Health Information Management Association as a RHIT or RHIA.
- Three to five years of inpatient coding experience is necessary for those with RHIT/RHIA credentials.
- Ability to work independently, self-motivated and an ability to adapt to the changing healthcare environment.
- Excellent verbal and written communication skills, analytical thinking and problem solving skills with attention to detail are required.
- Proficiency in organizational skills and planning with an ability to juggle multiple priorities in a fast changing environment.
- Proficiency in computer use, including database and spreadsheet analysis, presentation program, word processing and internet search.
- Ability to navigate the EHR to identify documents for review to provide accurate capture of clinical information.
- Prefer two to three years’ experience in a large academic medical center for RHIT/RHIA, NP, PA, RN, and MD.
- Experience as a Clinical Documentation Specialist is desired.
- Experience using UMHHC information systems/applications is desired.
- Certification as an RN, or a bachelor’s degree and certification in Nursing and or NP, PA or MD.
Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings. Background screenings are performed in compliance with the Fair Credit Report Act.
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- Creating a work environment in which people treat each other with respect and dignity, regardless of roles, responsibilities or differences.
- Providing support, direction and resources enabling us to accomplish the responsibilities of our jobs and to reach the goals that are set for professional and personal growth.
Job openings are posted for a minimum of seven calendar days. This job may be removed from posting boards and filled anytime after the minimum posting period has ended.
U-M EEO/AA Statement
The University of Michigan is an equal opportunity/affirmative action employer.