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Clinical Documentation Spec RN

Traverse City, MI


Posted on October 27, 2018

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About Clinical Documentation Spec RN


Bachelor of Science in Nursing and currently licensed as a Registered Nurse in the State of Michigan OR Certified Coding Specialist (CCS)

Three years’ experience in acute inpatient care nursing or inpatient coding required. Experience in Critical Care or Med-Surg. highly desirable.

In-depth knowledge of prospective payment, DRG and APC grouping, and ICD-9-CM and CPT classification systems is preferred.

Must be able to review and interpret clinical medical record information as it applies to coding and abstracting processes.

Experience in case management, utilization review or clinical documentation analysis preferred

Certified Clinical Documentation Specialist (CCDS) certification or eligibility highly desirable


Under the general supervision of the Director of Patient Financial Services.


 Cares for patients in the age category(s) checked below: __Neonatal (birth-1 mo) __Young adult (18 yr-25 yrs) __Infant (1 mo-1 yr) __Adult (26 yrs-54 yrs) __ Early childhood (1 yr-5 yrs) __ Sr. Adult (55 yrs-64 yrs) __Late childhood (6 yrs-12 yrs) __Geriatric (65 yrs & above) __Adolescence (13 yrs-17 yrs) __All ages (birth & above) 

X No direct clinical contact with patients


  1. Supports the Mission, Vision and Values of Munson Healthcare

  2. Embraces and supports the Performance Improvement philosophy of Munson Healthcare.

  3. Promotes personal and patient safety.

  4. Has basic understanding of Relationship-Based Care (RBC) principles, meets expectations outlined in Commitment To My Co-workers, and supports RBC unit action plans.

  5. Uses effective customer service/interpersonal skills at all times.

  6. Completes initial reviews of patient records within 24?48 hours of admission for a specified patient population to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness; and (b) initiate a review worksheet

  7. Conducts follow-up reviews of patients every 2?3 days to support and assign a working or final DRG assignment upon patient discharge, as necessary

  8. Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed

  9. Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record

  10. Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge

  11. Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement

  12. Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership

  13. Educates members of the patient care team regarding specific documentation needs and reporting and reimbursement issues identified through daily and retrospective documentation reviews and aggregate data analysis

  14. Facilitates change processes required to capture needed documentation, such as forms redesign

  15. Partners with the coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine a working and final DRG, severity of illness, and/or risk of mortality

  16. Reviews and clarifies clinical issues in the health record with the coding professionals that would support an accurate DRG assignment, severity of illness, and/or risk of mortality

  17. Assists in the appeal process resulting from third-party reviews

  18. Performs other duties and responsibilities as assigned.

About Munson Healthcare

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