GENERAL SUMMARY:

Facilitates improvement in overall quality, completeness and accuracy of medical record documentation.

Completes admission reviews and works closely with coding staff to ensure accuracy in code assignments that reflect the patient's clinical status and care.

Initiates and maintains extensive interactions with physicians and mid-level providers to address the need for more detailed information in the medical record.|

Collaborates with healthcare professionals to ensure the severity of illness and level of services provided are accurately reflected in the medical record and to resolve physician queries and documentation issues prior to patient's discharge.|

Maintains accurate records of review activities, ensuring reports and outcomes of clinical documentation improvement (CDI) efforts are valid.|

Provides education to the healthcare team on an ongoing basis regarding documentation opportunities, coding and reimbursement issues, and relevant quality and performance improvement activities.

Complexity of Work:
• Within scope of job, requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment.

Personal Protective Equipment:
• Follows Standard Precautions using personal protective equipment as required.

Requirements / Education:
Required Credential(s):

Registered Nurse credentialed from the Michigan Board of Nursing obtained prior to hire date or job transfer date Diploma from an accredited school/college of nursing OR required professional licensure at time of hire. ICU experience preferred  Knowledge of coding guidelines preferred  Must pass Nuance exam with 70% or better Additional Information Organization: Corporate Services Department: Ascension CDI - DRG Shift: Day Job Union Code: Not Applicable