Group Clinical Documentation & Denial Prevention Specialist - Full time (HYBRID)

Clinical Documentation & Denial Prevention Specialist

Are you a clinical detective with a passion for precision? We're looking for a strategic leader to bridge the gap between high-quality patient care and accurate medical reporting. In this role, you won't just review charts; you'll be the architect of a more resilient, compliant, and efficient healthcare system. How you'll make an impact:

• Guardian of Accuracy: Perform daily deep-dives into medical records to ensure the severity of illness and intensity of services are captured with clinical integrity.
• Denial Architect: Analyze clinical status and treatment plans to proactively resolve ambiguities, drastically reducing denials through advocacy and process improvement.
• Clinical Educator: Transform complex compliance requirements into actionable knowledge by developing and leading documentation training programs for all medical staff.
• Strategic Consultant: Partner with the medical records and utilization management committees, providing the data-driven insights and statistics needed to steer hospital-wide quality assurance.
• Quality Advocate: Implement sophisticated workflows that ensure every patient's story is told accurately, securing the resources they need for recovery.

What you bring:

• A keen clinical eye capable of synthesizing lab results, diagnostic data, and provider notes into a cohesive medical narrative.
• The expertise to navigate utilization management standards and medical necessity requirements.
• A collaborative spirit ready to mentor multidisciplinary teams on documentation best practices.

Job summary:

• Perform thorough daily review of medical records to ensure they accurately reflect the level of care provided and compliance with medical necessity documentation requirements.
• Analyze the medical record regarding the clinical status of patient, current treatment plan and past medical history and seek clarification of incomplete, unclear, and ambiguous documentation.
• Develop and implement plans for both formal and informal education of attending provider, nursing, social worker and other clinical staff.
• Provide education and training to staff on clinical documentation best practices and medical necessity criteria.
• Collaborate with attending providers to ensure clinical information is accurately and comprehensively documented.
• Intervene with clinical and medical staff to ensure documentation supporting applicable diagnosis.
• Provide education to providers and other clinicians on compliant documentation practices to support medical necessity, severity, reimbursement and continuity of patient care.

Career with Hartgrove Behavioral Health System offers:

• A rewarding career improving the lives of youth and adults
• Resources of a large health system (UHS, Inc.)
• An engaged leadership team
• A commitment to patient safety
• Career advancement and mobility
• Competitive compensation & benefits package and sign-on bonus
• And much more!

Qualifications:

• Education: BS in Nursing or Masters degree in Social Work or Psychology.
• Experience: Minimum three years of clinical experience in a hospital setting. At least one year experience in utilization management or knowledge of Medicare, Medicaid and managed care preferred.
• License: LCPC, LCSW or RN preferred.
• Knowledge: Possesses knowledge of utilization review, insurance and managed care procedures. Comprehensive understanding of medical necessity criteria (InterQual, MCG, CALOCUS, LOCUS, ASAM) for acute inpatient behavioral health. Knowledgeable in behavioral health managed care and clinical assessment skills to align patient acuity with level of care practice guidelines - Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Knowledge of DSM, ICD-10 and clinical best practices for treatment for medical, mental health and chemical dependency diagnoses, across all age spans preferred.
• Effective oral and written communication skills.
• Current knowledge of regulating/accrediting agency guidelines.
• Basic knowledge of computer skills and statistical analysis desired.

Supervision received: Group Director of UM. Supervision exercised: None. Line of promotion: UM Manager. Working conditions: General hospital environment. Physical requirements: Sedentary work with occasional lifting required. Important physical capabilities: bending, reaching, standing, listening, verbal skills, pushing, walking and repetitive typing/keying. Must be able to use computer, printer, typewriter and office supplies. The physical requirements described here are representative of those which must be met by an employee to successfully perform the functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the primary functions.

Job classification: Exempt.

About Universal Health Services: One of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance, growing since its inception into a Fortune 500 corporation. Headquartered in King of Prussia, PA, UHS has 99,000 employees. Through its subsidiaries, UHS operates 28 acute care hospitals, 331 behavioral health facilities, 60 outpatient and other facilities in 39 U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.

EEO Statement: All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. We believe that diversity and inclusion among our teammates is critical to our success.

Notice: At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skillset and experience with the best possible career path at UHS and our subsidiaries. We take pride in creating a highly efficient and best in class candidate experience. During the recruitment process, no recruiter or employee will request financial or personal information (Social Security Number, credit card or bank information, etc.) from you via email. The recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you are suspicious of a job posting or job-related email mentioning UHS or its subsidiaries, let us know by contacting us at: or 1-800-85.