Summary
The Clinical Documentation Specialist (CDS) is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the acuity and severity of illness of the patient, as well as the level of services and procedures rendered. The CDS assesses clinical documentation through extensive review of the medical record, interaction with physicians, advanced practice providers, ancillary clinical staff, and coding specialists, to ensure that appropriate reimbursement is received for the patient care services rendered, and the clinical information utilized in profiling and reporting outcomes is complete and accurate.
Hybrid: Must be able to come onsite to our Milwaukee campus as needed.
Primary Responsibilities
- Facilitates appropriate clinical documentation to support appropriate assignment of CPT/HCPCS and ICD-10-CM codes, as well as pertinent modifiers.
- Analyzes clinical status of patient, current treatment plan, past medical history and identifies potential gaps in provider documentation. Communicates with providers verbally or through written or electronic methodology to validate observations and if appropriate, query for more specific documentation and/or diagnoses via concurrent query process guidelines. Applies clinical knowledge and expertise to accomplish optimal identification of patient’s condition in the medical record.
- Participate in and take an active role in the identification, management, and development of Epic enhancements regarding clinician documentation and billing, including alignment of clinical documentation with coding rules and guidelines.
- Collaborate closely with providers and end-users to understand their operational needs and workflows, serving as a key liaison for Epic clinical documentation enhancements and training needs.
- Provide training to coding/charge capture and billing office staff on updates to Epic clinical documentation workflows and processes.
- Maintain up to date knowledge of EPIC as needed to support the implementation of changes needed.
- Collaborate with revenue integrity, coding, and billing office staff to promote complete and accurate clinical documentation and correct negative trends.
- Displays leadership and accountability, serving as a coach and role model. Communicates effectively, timely and in an open, honest manner. Shares knowledge and skills with colleagues and others.
- Bases decisions on facts, knowledge, and standards.
- Provide 1:1 and small group education to providers and staff on clinical documentation optimization and compliant coding & billing practices. Develop education materials and tools relative to documentation optimization practices presented as handouts, Power Points, etc.
- Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), and hierarchical condition category (HCC) diagnoses.
- Utilize software systems to collect, track, and report outcomes. Requires proficiency in abstracting and data entry into databases use for clinical documentation. Maintains integrity of data collection.
- Other duties as assigned.
Knowledge – Skills – Abilities
- Knowledge of regulations and guidelines pertaining to professional services clinical documentation and coding.
- Broad knowledge of health care payer policies, rules and government payer rules and regulations.
- In-depth knowledge of CDI process, workflow management and electronic health records (EPIC). Proficiency in CPT/HCPCS and ICD-10-CM coding.
- Strong leadership and interpersonal skills. Excellent written and oral communication skills, including excellent presentation skills and the ability to communicate effectively with all levels of management and medical providers.
- Ability to prioritize work, meet deadlines, and produced quality results on time with strong attention to detail.
- Ability to conduct basic research, analyze and interpret data, evaluate processes, and propose solutions. Proficiency with Microsoft Office Suite and EPIC.
- Ability to ensure a high level of customer satisfaction including faculty, advanced practice providers, and other departmental; staff within MCW/FH network.
Qualifications
Appropriate experience may be substituted for education on an equivalent basis.
Minimum Required Education: Bachelor’s degree in healthcare administration, business administration, IT, health informatics, nursing (Associates or Bachelor’s), or a similar field
Minimum Required Experience: Five (5) years’ experience in a similar or relevant role.
Preferred Experience: Eight+ (8+) years in professional services coding, clinical documentation improvement, and/or nursing.
Required Certification/Licensure(s): Coding Certification (CPC, CCS-P, RHIT, RHIA) or CDI Certification through AHIMA (CDIP) or ACDIS (CCDS, CCDS-O). Or Current WI Nursing License (RN, LPN).
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Physical Requirements
Work requires occasionally lifting moderate weight materials, standing, or walking continuously.
Work Environment
Occasional exposure to dust, noise, temperature changes, or contact with water or other liquids. Work is performed in an environmentally controlled environment.
Sensory Acuity
Ability to detect and translate speech or other communication required. May occasionally require the ability to distinguish colors and perceive relative distances between objects.
Why MCW?
- Outstanding Healthcare Coverage, including but not limited to Health, Vision, and Dental. Along with Flexible Spending options
- 403B Retirement Package
- Competitive Vacation and Paid Holidays offered
- Tuition Reimbursement
- Paid Parental Leave
- Employee & Family Assistance Program (EFAP)
- Pet Insurance
- On campus Fitness Facility, offering onsite classes
- Additional discounted rates on items such as: Select cell phone plans, local fitness facilities, Milwaukee recreation and entertainment etc.
For a brief overview of our benefits see: Benefits Overview
For a full list of positions see: MCW Careers
At MCW all of our endeavors, from our internal operations to our interactions with our partners, are driven by our shared organizational values: Caring – Collaborative – Curiosity – Inclusive – Integrity – Respect. We are committed to fostering an inclusive environment that values diversity in backgrounds, experiences, and perspectives through merit-based processes and in alignment with all applicable laws. We believe that embracing human differences is critical to realize our vision of a healthier world, and we recognize that a healthy and thriving community starts from within. Our values define who we are, what we stand for and how we conduct ourselves at MCW. If you believe in embracing individuality and working together according to these principles to improve health for all, then MCW is the place for you. For more information, please visit our institutional website.
MCW as an Equal Opportunity Employer and Commitment to Non-Discrimination:
The Medical College of Wisconsin (MCW) is an Equal Opportunity Employer. We are committed to fostering an inclusive community of outstanding faculty, staff, and students, as well as ensuring equal educational opportunity, employment, and access to services, programs, and activities, without regard to an individual's race, color, national origin, religion, age, disability, sex, gender identity/expression, sexual orientation, marital status, pregnancy, predisposing genetic characteristic, or military status. Employees, students, applicants or other members of the MCW community (including but not limited to vendors, visitors, and guests) may not be subjected to harassment that is prohibited by law or treated adversely or retaliated against based upon a protected characteristic.
