Clinical Documentation Specialist

Clinical Documentation SpecialistThe Clinical Documentation Specialist (CDS) is responsible for planning, coordinating and providing education to faculty, APPs, and house officers related to clinical documentation improvement and clinical revenue optimization for the Department of Otolaryngology Head and Neck Surgery and the UMMG. Apply knowledge of medical terminology and coding to create and implement education plans and communicate the principles and importance of accurate and complete documentation to ensure appropriate payment for clinical services both professional and facility. Partner with the departments Physician Champion to identify gaps and opportunities for revenue capture and assist with implementation of processes in the inpatient and ambulatory clinical settings. Understand and articulate data and analysis specific to faculty/APP/house officer clinical documentation, charge capture, and revenue activity. Provide updates to leaders on status and progress of efforts to improve revenue capture. Maintain strong collaborative relationship with the Revenue Cycle department via the Revenue Quality Liaison (RQL).Core Responsibilities and Expectations :Serves as the primary source of contact and resource for faculty, APPs, and house officers with regard to clinical documentation and medical coding for patient care servicesDevelops tools to assist providers with efficient, effective documentation and accurate codingPrepares reports to provide feedback on provider and coding performance including state of documentation, charge capture, and reconciliationIdentifies documentation trends to be shared with the Physician Champion to allow for clinician educationProvides group and one-on-one education for faculty, APPs, and house officers, as neededPrepares case and specialty specific documentation examples and power point presentations to be shared at department meetingsAnalyzes data to prioritize areas of RVU recoveryAssists with UMMG and department initiatives to improve revenue and reduce avoidable write offsDevelops strategies to optimize inpatient and outpatient charge capture and facilitate change processes requiredServes as a resource on documentation requirements and ensure compliance with applicable laws and regulationsAssists faculty leadership in onboarding new faculty and other providers with orientation to documentation, coding and reportsPerforms chart reviews for the purpose of providing feedback to individual providersPartners with the RQL to ensure smooth handoffs and follow-up to units within Revenue Cycle and ensure consistent communication between all partiesMaintains current with specialty coding updates, work processes, tools, and clinical and administrative applications necessary to perform job functionsProject a professional and positive image when interacting with patients, faculty and staffPerforms other duties appropriate to the CDS function, as assignedDepartment Specific Responsibilities and Expectations :Function as a credentialed MiChart Super User, providing expert guidance of application of MiChart to all coding, documentation and other key activitiesServe as liaison to coding, billing, charge integrity, ACU referral coordinator teams, and HIM teamsMonitor complex billing codes on a regular basis to ensure appropriate charge captureMonitor E&M coding relative to appropriate leveling and overall distributionMonitor inpatient services and bedside procedures to enhance revenue potentialMonitor open encounters and incomplete operative notes, and assist providers with completing documentation as requestedDevelop reports followed by root cause analysis for strategical optimization of activitySupport training and provide assistance as needed to ACU staff in Point of Service work queue managementProvide information as requested to support Revenue Cycle team members in the management of coding and other work queuesDraft letters for denied services, in partnership with appropriate clinical leadersProvide input on operational changes that would lead to enhanced revenue capture/generationProvide ad hoc queries using HSDW, Tableau and other tools to support decision-makingAssist with other tasks as necessarySupervision :The CDS will be supervised by the Chief Department Administrator or designee. The CDS does not have supervisory responsibilities.Required Qualifications*Demonstrated ability to model and lead the Department of Otolaryngology's core values: Inclusion, Engagement, Civility and Accountability.Associate's degree or equivalent educationAt least five years of medical coding experienceCurrent RHIT, RHIA or CPC certificationDemonstrated experience providing effective clinical documentation and coding education to providersExcellent communication skills (verbal and written) to enable effective outcomes with the diverse complex clinical care teams.Ability to navigate the EHR to identify documents for review to provide accurate capture of clinical information.Extensive CPT and ICD-10 coding knowledgeMedical terminology and clinical knowledge with the ability to review documentation and determine what documentation is needed to provide accurate medical codesAbility to work independently, be self-motivated and adapt to the changing healthcare environmentProficiency in organizational skills and planning with an ability to juggle multiple priorities and meet key deadlines, in a fast-changing environment.Proficiency in computer use including Microsoft Office Suite experienceProvide support to clinicians on navigating the EHR to make addendums, create SmartTexts and SmartPhrases and utilize templatesAttention to detail with thoroughness and accuracy when accomplishing a taskPossess proactive, strategic, innovating and out-of-the-box thinkingFlexibility to work effectively both on-site and remotelyDesired Qualifications*Knowledge and experience of otolaryngology coding patterns, rules and revenue cycle operational workflowsExperience working with surgical services/surgeons and associated team membersSelf-starter with demonstrated ability to work both independently and collaboratively in a team settingProficiency with EPIC softwareDemonstrated ability to manage time effectively with a high degree of accuracy while working in an environment of fluctuating priorities and interruptionsHighly proactive, a high degree of problem-solving skills, a high sense of ownership and accountability for workload, and flexibility during times of changeExperience with data queries and report generationExperience presenting complex information effectively to groupsAdvanced knowledge of Tableau, Health System Data Warehouse (HSDW) and Microsoft Excel to provide advanced analysis to leadership