Documentation Specialist Rn Jobs

The Documentation Specialist RN facilitates accurate and timely clinical documentation in the medical record to capture severity of illness through collaboration with clinicians, providers, coding professionals, and nursing staff to support the coding process and appropriate DRG assignment. The Specialist RN uses the Code of Ethics for Nurses with Interpretive Statements to guide leadership and practice.

Provide education to providers and appropriate staff related to Certified Data Management Professionals(CDMP) principles and documentation improvement.

Timely follow up on all cases especially those with clinical documentation clarification.

Participate in monthly Task Force and Staff Meetings.

Manage multiple priorities.

Accurate input of data into CDMP Trak®.

Weekly impact review of all cases with clarifications via CDMP Trak®.

All other duties as assigned.

NSC - Nursing Specialty Certification Preferred

CCDS- Certified Documentation Specialist preferred within 3 years of hire.

RN - Registered Nurse Required

Current Registered Nurse license in the state of Michigan required.

Associates Degree

Bachelor’s degree in nursing at time of hire or transfer to position preferred.

Knowledge of nursing practices and procedures as normally acquired through 3 years’ experience working in a Medical Center or similar setting.

Organizational, analytical, writing, and interpersonal skills.

Dependable, self-directed with excellent time management skills.

Critical thinking, problem-solving and deductive reasoning skills.

Minimum of 5 years of clinical experience -preferably critical care or strong Med/Surg background.

Knowledge of Pathophysiology and Disease Process. Basic Computer skills – familiarity with Windows based software programs.

Knowledge of Medicare Part A.

Familiar with Medicare Part B. Knowledge of regulatory environment.

Understand and support CDMP® documentation strategies (upon completion of training).

Must follow MyMichigan Health blood borne pathogen and TB testing as required.

MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft® Windows.

An employee may be required to participate in further learning opportunities offered by MyMichigan Health.