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

Clinical Documentation & Denial Prevention Specialist

Responsibilities: 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

The Clinical Documentation & Denial Prevention Specialist responsibilities include: Performing thorough daily review of medical records to ensure they accurately reflect the level of care provided and compliance with medical necessity documentation requirements. Analyzing the medical record regarding the clinical status of patient, current treatment plan and past medical history and seeking clarification of incomplete, unclear, and ambiguous documentation. Developing and implementing plans for both formal and informal education of attending provider, nursing, social worker and other clinical staff. Providing education and training to staff on clinical documentation best practices and medical necessity criteria. Collaborating with attending providers to ensure clinical information is accurately and comprehensively documented. Intervening with clinical and Medical Staff to ensure documentation supporting applicable diagnosis. Providing 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! For information about the benefits we offer, please visit UHS Benefits Service Center

Qualifications

JOB SPECIFICATIONS: To perform this job successfully, an individual must be able to perform each primary duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Education: BS in Nursing or Masters degree in Social Work or Psychology. Experience: Minimum three years of clinical experience 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