Team Lead Clinical Documentation

DMC Harper University Hospital is committed to providing exceptional patient care in a supportive and collaborative environment. As a member of our team, you will have the opportunity to work with advanced technology and be part of a healthcare community dedicated to making a positive impact on the lives of our patients.

At Tenet Healthcare, we understand that our greatest asset is our dedicated team of professionals. That’s why we offer more than a job – we provide a comprehensive benefit package that prioritizes your health, professional development, and work-life balance. The available plans and programs include:

• Medical, dental, vision, and life insurance
• 401(k) retirement savings plan with employer match
• Generous paid time off (PTO)
• Career development and continuing education opportunities
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, auto & home insurance.

Under general supervision and according to established policies and procedures, assists in planning, organizing, coordinating and implementing clinical documentation guidelines including coding practices, reviewing reimbursement, maintaining optimal quality care documentation as it relates to pay for performance initiatives for Detroit Market Adult Hospitals. Coordinates the work of assigned professional and technical personnel. Participates in clinical research projects and clinical case conferences and various staff competency and development programs.

• Provides assistance in planning, organizing and implementing clinical documentation improvement practices as related to impact on accuracy and completeness of the medical record, quality of care, LOS/Excess Days, and CMI.
• As a team leader, coordinates and delegates the work of assigned professional and technical personnel to achieve departmental/program objectives. Schedules, evaluates competency and work completion of assigned areas for professional and technical staff.
• Provides facilitation of necessary documentation in the medical record through extensive interaction with physicians, nursing staff, other patient caregivers, and collaboration with HIM coding staff to ensure the most appropriate reimbursement is achieved for the level of service rendered to all patients. Participates in patient care rounds and consults with health care providers to ensure most effective documentation.
• Participates in the development of goals and objectives, workload reporting, budget development for specific service areas and monitoring of these objectives. Develops, secures approval of and implements policies and procedures specific to clinical documentation. Monitors and develops revisions to processes as necessary.
• Assists in the planning and implementation, data collection, analysis and documentation of CDS' daily work activities.
• Assists in planning monthly CDIS/hospital leadership meetings, including presentation of monthly CDIS statistics and scorecards. Follows-up on deficiencies in statistics.
• Monitors procedures and processes to identify improvements, formulates recommendations, secures approvals, and facilitates implementation.
• Assists in the selection, hiring, evaluation, discipline and/or discharge of assigned CDIS staff.
• Performs other duties as assigned.

• Graduate from an accredited school of Nursing. Bachelor's degree in Nursing preferred. License to practice as a Registered Nurse in the State of Michigan. Three years of…