Lakeland Health

RN Clinical Documentation Specialist (Health Information Management) (44395952)
Location: St Joseph, Michigan - United States
Posted: 12/12/2017

RN Clinical Documentation Specialist (Health Information Management)

Full-Time Monday-Friday 8:00am-5:00pm Day Shift Responsibilities: Communicate with providers, care managers, coders, and other health care team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients. Provide education to all internal customers related to compliant documentation and coding as directed. Act as consultant to coders when additional information or documentation is needed to assign the correct MS-DRG and APR-DRG. Complete review of medical record for each assigned patient in the time frame and frequency as required. Communicate with providers face to face and via electronic health record. Follow up with appropriate health team members to ensure accurate and complete documentation in the medical record. Demonstrate an understanding of complications, comorbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on DRG, and is able to impart this knowledge to physicians and other health care members. Identify the most appropriate principal diagnosis and secondary diagnoses to accurately reflect the severity of illness and risk of mortality. Requirements: Current RN license in state of Michigan. Previous experience that demonstrates leadership skills normally acquired through higher education. Minimum of 3 years of recent clinical experience in an acute care setting. Must have advanced communication and interpersonal skills with all levels of internal and external customers. Excellent written/verbal communication, critical thinking, creative problem solving and conflict management skills. Proficient organization and planning skills. Basic computer, data entry, typing, filing and organization skills required.

Additional Requirments / Information

Job Capacity:Employee (full-time)
Minimum Education Level:See Job Description
Visa Sponsorship: No
Related Industries:Nursing, Education/Training

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