Overview
UP Health System – Marquette
/Clinical Document Specialist, CDI, 1.0DV/
*Who We Are:*
People are our passion and purpose. Come work where you are appreciated for who you are not just what you can do. UPHS – Marquette is a 222 bed hospital and houses the region’s only Level II Trauma Center and Neonatal Intensive Care Unit (NICU). We also provide outreach with programs like annual health and safety fairs, health screenings for the entire family and more to keep our community healthy!
*Where We Are:*
In Marquette our fascinating history, rural landscape, abundant recreational opportunities, and welcoming people make the Upper Peninsula someplace special. From a thriving culinary scene to charming shops to historic lighthouses and museums, there is something for everyone in this beautiful lakeside gem.
*Why Choose Us:*
Health (Medical, Dental, Vision) and 401K Benefits for full-time employees
Competitive Paid Time Off / Extended Illness Bank package for full-time employees
Employee Assistance Program – mental, physical, and financial wellness assistance
Tuition Reimbursement/Assistance for qualified applicants
Opportunities for education and training through partnership with Duke LifePoint Healthcare
And much more…
*Position Summary:*
Facilitates improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients. Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assist with education and training related to improving clinical documentation.
Reports to: Manager
FLSA: Non-exempt
EEO: □ 01 Officials and Managers □ 02 Professionals □ 03 Technicians □ 04 Sales Workers X 05 Administrative Support Workers □ 06 Craft Workers □ 07 Operatives □ 08 Laborers and Helpers □ 09 Service Workers
ESSENTIAL FUNCTIONS
Conducts daily reviews of inpatient medical records to identify missing, vague, and/or incomplete diagnoses and procedures. Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and queries left in the medical record have been answered by the provider.
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Utilizes coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes.
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Queries physicians on specificity of procedures performed and diagnoses based on accepted coding guidelines, clinical expertise and LifePoint Hospitals query policy.
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Tracks and trends specific opportunities for CDI process improvement through the utilization of metrics reports.
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Conducts educational sessions with physicians and other health care team members on documentation requirements.
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Prepares and presents educational programs to all internal constituents related to clinical documentation issues and coordinates same with clinical staff, physicians, compliance and coding staff.
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Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans.
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Assumes responsibilities for following compliance guidelines with federal, state, and local regulations within the department.
*Minimum Qualifications:*
Minimum Education
High school diploma or equivalent
Associate’s degree in Nursing (Preferred)
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Required Skills
Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.
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Required Skills
Licenses:
RN in State of Michigan (if graduated from RN program)
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Certifications: (one of the following is required if not an RN)
Certified Coding Specialist (C.C.S.)
Certified Professional Coder-Hospital (CPC-H)
Certified Coding Associate (CCA)
Registered Health Information Technician (RHIT)
Registered Health Information Administrator (RHIA)
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Minimum Work Experience
2 years hospital experience
*EEOC Statement:*
UP Health System – Marquette is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans’ status or any other basis protected by applicable federal, state or local law.
**Job:** **Administration/Clerical*
**Organization:** **
**Title:** *Clinical Document Specialist*
**Location:** *Michigan-Marquette*
**Requisition ID:** *7467-9004*
