CLINICAL DOCUMENTATION SPECIALIST

UMHP Clinical Documentation Specialist (CDS)

Positions Location: Lansing, MI

General Purpose of Job: The UMHP Clinical Documentation Specialist (CDS) is responsible for planning, coordinating and providing education related to clinical documentation improvement and clinical charge capture optimization for their assigned UM Health Partners market service line physicians, APPs and staff. The CDS will improve and optimize workflows and processes related to the education, analysis, maintenance and support of charging, coding, documentation, Annual Wellness Visits (AWVs), prior authorization, modifier usage trends/development, portal messaging and CPT/ICD-10 and HCC code usage for UMHP to achieve best in class. The CDS will apply their knowledge of medical terminology and coding to develop workflows, implement education plans and communicate the principles and importance of accurate and complete documentation to support charging for outpatient professional clinical visits/services, surgeries, procedures and imaging studies. The CDS identifies gaps and opportunities for charge capture and partners with the medical and service line leadership on the implementation of processes in the ambulatory clinical setting. The CDS understands and articulates data analysis specific to physician and APP clinical documentation, charge capture and revenue activity, provides updates on status and progress of efforts to improve revenue capture, and maintains a strong collaborative relationship with the Clinically Integrated Network (CIN) and other relevant departments.

Essential Duties:

• Assists in the design, implementation, education and evaluation of tools and resources to assist providers with efficient and effective documentation, accurate coding and charge capture opportunities.
• Provides coding and documentation education for physicians and APP's.
• Collaborates on education efforts.
• Develops upstream coding, documentation, charge capture, education approach focused on new departments and emphasizing new specialty areas to increase knowledge and establish sustainable best practices early on.
• Assists in onboarding process for physicians and APPs with orientation to documentation, coding and charge capture excellence, establishing a 3-to-9-month check-in/assessment process with all recently onboarded providers ensuring appropriate charge capture check-ins.
• Communicates with UMHP service line leaders, provider champions, physicians and APPs regarding clinical documentation and medical coding for patient care services.
• Prepares and analyzes reports to provide feedback on provider and coding performance including state of documentation, charge capture and reconciliation.
• Identifies Return on Investment, documentation trends and priority areas/pain points to share with site/service line leadership to allow for clinician education. Prepares case and specific documentation examples/presentations to share at department meetings.
• Analyzes data to prioritize areas of wRVU recovery.
• Assists with UMHP and department initiatives to improve revenue, centralize outpatient prior authorization processes and reduce avoidable write-offs.
• Assists with the strategic development of outpatient charge capture optimization (i.e. professional clinical visits/services, surgeries, procedures and imaging studies), and facilitates change processes required.
• Performs chart reviews for the purpose of providing feedback to individual providers, ensuring smooth handoffs and follow-up to sites/service lines and consistent communication between all parties.
• Identifies educational opportunities to improve and enhance learning. Maintains current with specialty coding updates, work processes, tools, and clinical and administrative applications necessary to perform job functions.
• Serves as a resource on documentation requirements and ensures compliance with applicable laws and regulations.
• Builds and maintains positive working relationships throughout the organization that enable efficient leadership through projects involving change management or complex cross-departmental collaboration.

Job Requirements:

• RHIT, RHIA, CCS, CCS-P, CPC or other professional HIM coding certificate • EPIC or Revenue Cycle Certification – preferred • Clinical Documentation certification – preferred

• At least three (3) years of experience with healthcare documentation, coding requirements or revenue cycle experience • At least one (1) year of experience as an educator or trainer in a healthcare setting • Prior clinical experience – preferred • Experience using EPIC – preferred

• Associate degree in Business, Nursing or related field; or equivalent experience in medical billing, coding, health information technology/management, health administration, business administration or another related field.

• Demonstrated experience providing clinical documentation and coding education to providers. • Excellent communication skills (verbal and written) to enable effective outcomes with the diverse complex clinical care teams. • Ability to navigate the EHR to identify documents or review to provide accurate capture of clinical information. • Extensive CPT and ICD-10 coding knowledge. • Medical terminology and clinical knowledge with the ability to review documentation and determine what documentation is needed to provide accurate medical codes. • Ability to work independently, self-motivated and an ability to adapt to the changing healthcare environment. • Proficiency in organizational skills and planning with and ability to juggle multiple priorities in a fast-changing environment. • Proficiency in computer use including Microsoft Office Suite experience. • Provide support to clinicians on navigating all functions of the EHR. • Possess proactive, strategic, innovating and out-of-the-box thinking. • Demonstrates attention to detail, consistency, and meets multiple deadlines in a timely manner. • Demonstrates leadership, independence, responsibility, accountability and good judgment. Ability to think strategically. • Acts as a self-starter and demonstrate a willingness to take on new and challenging leadership roles, as well as non-leadership projects and deliverables. • Accepts and respects diversity without judgment.

University of Michigan Health - Sparrow is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veteran status.