Clinical Documentation Spec

Clinical Documentation Specialist

The Clinical Documentation Specialist (CDS) is responsible for planning, coordinating, and providing education (in various forms and delivery pathways) to faculty, APPs, and residents related to clinical documentation improvement and clinical revenue optimization for the Department of Radiation Oncology and the University of Michigan Medical Group (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 department’s Physician Champion(s) and administrator to identify gaps and opportunities for revenue capture and assist with the implementation of processes in the inpatient and ambulatory clinical settings. Understand and articulate data and analysis specific to Faculty/APP/Residents clinical documentation, charge capture, and revenue activity. Provide updates to leaders on status and progress of efforts to improve revenue capture. Maintain a 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 residents regarding clinical documentation and medical coding for patient care services
• Develops tools and educational content (tips, tricks, billing pearls, slide decks, videos, etc. delivered electronically, in-person and/or via remote technology) 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(s) to allow for clinician education
• Provides group and one-on-one education for faculty, APPs, and residents, as needed
• Prepares case and specialty specific documentation examples and PowerPoint presentations to be shared at department meetings
• Analyzes data to prioritize areas of wRVU 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 in onboarding new faculty with orientation to documentation, coding, and reports
• Performs chart reviews to provide 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 faculty, and staff
• Performs other duties appropriate to the CDS function, as assigned

Department Specific Responsibilities and Expectations:

• Denial prevention. Monitor precertification process and provide continuous needs assessment. Assist with audits, appeals, and peer-to-peer reviews. Collaborate with coder/biller education
• Denial reporting. Establish review parameters and identify priorities. Provide denial assistance, identify areas of deficiency, and define organizational impact
• Revenue optimization. Establish benchmarks and metrics. Develop projections and track revenue increase.

Required Qualifications:

• Associates degree or equivalent
• At least five years of medical coding experience and related equivalent experience
• Current RHIT, RHIA or CPC certification
• Extensive CPT and ICD-10 coding knowledge
• Working knowledge of CMS LCDs
• Familiarity and/or experience with NCCI edits
• Medical terminology and clinical knowledge with the ability to review documentation and determine what documentation is needed to provide accurate medical codes
• Ability to navigate the EHR to identify documents for review to provide accurate capture of clinical information.
• Ability to support clinicians on navigating the EHR to make addendums, create SmartTexts and SmartPhrases and utilize templates
• Demonstrated experience providing clinical documentation and coding education to providers
• Excellent communication skills (verbal and written) to enable effective outcomes with diverse complex clinical care teams.
• Ability to work independently, be self-motivated, and an ability to adapt to the changing healthcare environment
• Proficiency in organizational skills and planning with an ability to juggle multiple priorities in a fast-paced environment.
• Demonstrated ability to organize and execute projects from inception through completion.
• Proficiency in computer use including Microsoft Office Suite experience
• Attention to detail with thoroughness and accuracy when accomplishing a task
• Possess proactive, strategic, innovative and out-of-the-box thinking
• Flexibility to work on-site and remotely

Desired Qualifications:

• Familiarity and/or experience with Radiation Oncology coding
• Ability at identifying, preventing, and alleviating workflow barriers to clinical practice

Why Join Michigan Medicine?

The Department of Radiation Oncology at the University of Michigan (part of Michigan Medicine) is a nationally recognized academic and clinical program focused on cancer treatment using advanced radiation therapies.

Radiation Oncology at the University of Michigan began as part of the Radiology Department under the leadership of Dr. Isadore Lampe. In 1984, it became a separate department and leader in the field, chaired by Allen Lichter, MD. Dr. Lichter encouraged physics research leading to the development of computerized treatment planning, clinical trials validating IMRT and other new therapies as well as cancer biology investigations both at the basic science level and as translational work leading to clinical trials. He also helped establish the first of the department's community practices outside of Ann Arbor.

U-M Health's Radiation Oncology Program is led by a competent and caring team of physicians who are experts in their field, exceptional nurses with radiation oncology training, certified radiation therapists, highly trained medical physicists and many other specialists who are committed to providing the best care for our patients.

Our department has faculty practicing statewide across Ann Arbor, Brighton, Lansing, Wyoming, Grand Rapids, & Muskegon.

The department treats thousands of patients annually across a wide range of cancers & benign diseases. We serve both adult and pediatric populations. Our core therapies include external beam treatments (3-D, IMRT), stereotactic radiosurgery & radiotherapy, high-dose rate and low-dose rate Brachytherapy & prostate seed implants. These delivery methods paired with industry leading treatment devices allow high precision targeting of treatment sites while sparing surrounding normal tissue. To further customize treatments for patients, we provide adaptive radiation therapy using functional and metabolic imaging in addition to daily anatomical imaging.

As part of our tri-partite mission of research, education and clinical care, we both initiate and participate in clinical trials to develop the next generations of treatment and care, often in cooperation with other departments at the University of Michigan and institutions nationwide. Our training programs for physicians, therapists and physicists have developed industry leaders and in academia and private practices across the U.S. and abroad.

Modes of Work

Positions that are eligible for hybrid or mobile/remote work mode are at the discretion of the hiring department. Work agreements are reviewed annually at a minimum and are subject to change at any time, and for any reason, throughout the course of employment. Learn more about the work modes.

Additional Information

Supervision:

The CDS will be supervised by the Business Process Consultant Lead. The CDS does not have supervisory responsibilities.

Background Screening

The University of Michigan conducts background checks on all job candidates upon acceptance of a contingent offer and may use a third party administrator to conduct background checks. Background checks are performed in compliance with the Fair Credit Reporting Act.

U-M EEO Statement

The University of Michigan is an equal employment opportunity employer.