Clinical Documentation Spec

University of Michigan • Ann Arbor, MI • 3h ago

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Job Summary

This key role is instrumental in improving the quality and completeness of provider-based clinical documentation within inpatient medical records. The CDIS will ensure the accurate representation of a patient's clinical status, affecting key metrics such as Present on Admission (POA), Severity of Illness (SOI), and Risk of Mortality (ROM) scores, while also influencing hospital reimbursement and the level of services provided. Collaboration with physicians and other clinical staff is essential to ensure comprehensive documentation that supports correct coding assignments at discharge. Additionally, the role involves creating and implementing an educational plan targeted at providers, emphasizing the principles of precise and complete documentation and its impact on SOI, ROM, and Length of Stay (LOS).

Mission Statement

Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally. Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.

Responsibilities*

Perform initial reviews of inpatient Pediatrics records to identify opportunities for clinical documentation improvement, impacting metrics such as DRG assignment, PSI, HAC, SOI, ROM, POA, and Risk O:E, as well as risk adjustment and accurate code assignment for billing.

Conduct subsequent/follow-up reviews.

Utilize CDI software to determine appropriate DRG, SOI, ROM, risk, and POA assignment.

Evaluate clinical documentation, including signs, symptoms, lab results, diagnostic information, and treatment plans, to identify improvement opportunities, and engage in clarification with providers.

Initiate communication with clinicians through the formal query process.

Prepare case-specific documentation examples and PowerPoint presentations for clinical treatment teams and departments, relating to documentation and the Electronic Health Record (EHR).

Develop and conduct ongoing education programs for new staff, CDI specialists, physicians, and nursing personnel.

Adhere to the Health Information Management (HIM) Coding-CDI Query Policy and the Query Escalation Policy and follow standards of practice for quality and productivity.

Demonstrate proficiency in abstracting and data entry into all CDI-related databases.

Participate in and understand the Michigan Medicine annual SMART goal/evaluation process and CORE values.

Demonstrate initiative by continuously expanding knowledge and skills.

Engage in department/unit activities, including staff meetings, in-services, workgroups, and trial groups.

Involvement in third-party audit denials and appeal processes by reviewing denials and submitting supporting documentation/evidence for defense.

Perform other duties as assigned to maintain departmental efficiency.

Required Qualifications*

An Associate's degree in health information technology, registration with the American Health Information Management Association as a Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA), and/or certification as a Registered Nurse (RN), or a Bachelor's degree and certification in Nursing, Nurse Practitioner (NP), Physician Assistant (PA), or Medical Doctor (MD).

Three years of experience in an inpatient setting, either in coding or clinical roles.

Adherence to the Michigan Medicine remote work agreement.

Modes of Work

Positions that are eligible for hybrid or mobile/remote work mode are at the discretion of the hiring department. Work agreements are reviewed annually at a minimum and are subject to change at any time, and for any reason, throughout the course of employment. Learn more about thework modes (https://hr.umich.edu/working-u-m/my-employment/ways-we-work-resource-center/ways-we-work-implementation-group/modes-work) .

Background Screening

Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings. Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.

Application Deadline

Job openings are posted for a minimum of seven calendar days. The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled anytime after the minimum posting period has ended.

U-M EEO Statement

The University of Michigan is an equal employment opportunity employer.

Job Detail

Job Opening ID

273354

Working Title

Clinical Documentation Spec

Job Title

Clinical Documentation Spec

Work Location

Michigan Medicine - Ann Arbor

Ann Arbor, MI

Modes of Work

Mobile/Remote

Full/Part Time

Full-Time

Regular/Temporary

Regular

FLSA Status

Exempt

Organizational Group

Exec Vp Med Affairs

Department

MM Rev Cycle (PTO)

Posting Begin/End Date

2/02/2026 - 2/16/2026

Career Interest

Healthcare Admin & Support

Apply Now

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