Clinical Documentation Specialist

Clinical Documentation Specialist

The 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 services
• Develops tools to assist providers with efficient, effective documentation and accurate coding
• Prepares reports to provide feedback on provider and coding performance including state of documentation, charge capture, and reconciliation
• Identifies documentation trends to be shared with the Physician Champion to allow for clinician education
• Provides group and one-on-one education for faculty, APPs, and house officers, as needed
• Prepares case and specialty specific documentation examples and power point presentations to be shared at department meetings
• Analyzes data to prioritize areas of RVU recovery
• Assists with UMMG and department initiatives to improve revenue and reduce avoidable write offs
• Develops strategies to optimize inpatient and outpatient charge capture and facilitate change processes required
• Serves as a resource on documentation requirements and ensure compliance with applicable laws and regulations
• Assists faculty leadership in onboarding new faculty and other providers with orientation to documentation, coding and reports
• Performs chart reviews for the purpose of providing feedback to individual providers
• Partners with the RQL to ensure smooth handoffs and follow-up to units within Revenue Cycle and ensure consistent communication between all parties
• Maintains current with specialty coding updates, work processes, tools, and clinical and administrative applications necessary to perform job functions
• Project a professional and positive image when interacting with patients, faculty and staff
• Performs other duties appropriate to the CDS function, as assigned

Department 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 activities
• Serve as liaison to coding, billing, charge integrity, ACU referral coordinator teams, and HIM teams
• Monitor complex billing codes on a regular basis to ensure appropriate charge capture
• Monitor E&M coding relative to appropriate leveling and overall distribution
• Monitor inpatient services and bedside procedures to enhance revenue potential
• Monitor open encounters and incomplete operative notes, and assist providers with completing documentation as requested
• Develop reports followed by root cause analysis for strategical optimization of activity
• Support training and provide assistance as needed to ACU staff in Point of Service work queue management
• Provide information as requested to support Revenue Cycle team members in the management of coding and other work queues
• Draft letters for denied services, in partnership with appropriate clinical leaders
• Provide input on operational changes that would lead to enhanced revenue capture/generation
• Provide ad hoc queries using HSDW, Tableau and other tools to support decision-making
• Assist with other tasks as necessary

Supervision :

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 education
• At least five years of medical coding experience
• Current RHIT, RHIA or CPC certification
• Demonstrated experience providing effective 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 for 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, be self-motivated and adapt to the changing healthcare environment
• Proficiency 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 experience
• Provide support to clinicians on navigating the EHR to make addendums, create SmartTexts and SmartPhrases and utilize templates
• Attention to detail with thoroughness and accuracy when accomplishing a task
• Possess proactive, strategic, innovating and out-of-the-box thinking
• Flexibility to work effectively both on-site and remotely

Desired Qualifications*

• Knowledge and experience of otolaryngology coding patterns, rules and revenue cycle operational workflows
• Experience working with surgical services/surgeons and associated team members
• Self-starter with demonstrated ability to work both independently and collaboratively in a team setting
• Proficiency with EPIC software
• Demonstrated ability to manage time effectively with a high degree of accuracy while working in an environment of fluctuating priorities and interruptions
• Highly proactive, a high degree of problem-solving skills, a high sense of ownership and accountability for workload, and flexibility during times of change
• Experience with data queries and report generation
• Experience presenting complex information effectively to groups
• Advanced knowledge of Tableau, Health System Data Warehouse (HSDW) and Microsoft Excel to provide advanced analysis to leadership