company overview

Allegiance Health is a community-owned and locally-governed health system.

We are proudly entering our 10th decade of serving the people of south central Michigan with local, high-quality health care.

We staff our facilities with exceptional, caring professionals who are dedicated to the health and well-being of the communities we serve.

Comprised of more than 40 different facilities, our system reaches residents of Jackson, Hillsdale, Lenawee, Ingham, Calhoun and Washtenaw counties and beyond.

At Allegiance Health, we believe our community is best served by having the most advanced medical services combined with a progressive philosophy of overall wellness. Together, these two approaches will help our community become the healthiest in Michigan - our vision.

Clinical Documentation Specialist Apply for this job now!
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Job Overview
Company: Allegiance Health Job Type:
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job description

 

 

 

  • Provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans
  • Be responsible for the day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures
  • Communicate with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness
  • Communicate with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record
  • Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team
  • Gather and analyze information pertinent to documentation findings and outcomes. Communicate with physicians, case managers, coders, and other healthcare team members to facilitate comprehensive medical record documentation to reflect clinical treatment, decisions, and diagnoses for inpatients
  • Utilizes the hospital’s designated clinical documentation system to identify opportunities for physician and hospital outcomes
  • Provides or coordinates education to all internal customers related to compliance, coding, and clinical documentation issues and acts as a consultant to coders when additional information or documentation is needed to assign the correct DRG
  • Responsible for the day-to-day evaluation of documentation by the medical staff and healthcare team in accordance with the hospital’s designated clinical documentation system
  • Gather and analyze information pertinent to documentation findings and outcomes.  Contribute to a positive working environment and performs other duties as assigned or directed to enhance the overall efforts of the organization
  • Develop physician education strategies to promote complete and accurate clinical documentation and correct negative trends
  • Identify patterns, trends variances and opportunities to improve documentation review and process.  Research literature to identify new methods development and overall documentation enhancement
  • Assist in the development and reporting of performance measures to the medical staff and other departments and prepare physician specific data information
  • Actively participate on departmental and hospital committees and assigned Task Force groups. Comply with HIPPA and Code of Conduct policies
  • Maintain interaction with appropriate resources that support growth and education of the CDI Team
 


job Requirements

  • Currently licensed as a Registered Nurse, CCS or Coding experience desirable
  • Prefer BS in Nursing or Registered Nurse with ten years acute care experience or RHIA/RHIT with ten years inpatient coding experience
  • Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting
  • Clinical expert with at least 2 years recent inpatient experience
  • Excellent verbal and written communication skills
  • Proficiency in organization and planning
  • Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching
  • Understanding of organizational policies and procedures
  • Working knowledge of quality improvement theory and practice
  • Ability and willingness to seek out and accept change
  • Demonstrates adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice
  • Knowledge of federal, state and private payer regulations

     

     

     Let Allegiance Health help you balance work and home 
     

    • Concierge Service  

    • Success Share Bonus Plan 
    • On-site Wellness Center 
    •  Generous Paid-Time-Off Package 
    • Competitive Salaries and Extensive Flex-Benefits  

       

    Allegiance Health is a community-owned and locally-governed health system. We are proudly entering our 10th decade of serving the people of south central Michigan with local, high-quality health care.
     

    We staff our facilities with exceptional, caring professionals who are dedicated to the health and well-being of the communities we serve. Comprised of more than 40 different facilities, our system reaches residents of Jackson, Hillsdale, Lenawee, Ingham, Calhoun and Washtenaw counties and beyond.

    At Allegiance Health, we believe our community is best served by having the most advanced medical services combined with a progressive philosophy of overall wellness. Together, these two approaches will help our community become the healthiest in Michigan – our vision. 
     

    • A few highlights of our heath system include: 

    •  Service in the Jackson area since 1918.

    •  A 411-bed system with a full range of inpatient and outpatient services.  

    • More than 330 physicians and 3,200 staff members.   

    • New, state-of-the-art surgery facilities.

    •  A 20-bed cardiac universal bed unit for treating heart surgery patients.  

    • An outpatient surgery center for same-day procedures.  
    • A new hospice residence  
    • A new emergency department   

    • Primary health services for the underserved, regardless of their ability to pay, through the Center for Family Health.

    • 20,000 patients admitted per year  

    • 60,000 emergency department visits per year

       

    •  

     

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