Summary
The Professional Billing CDI Clinical Specialist is an advanced practice provider role responsible for optimizing documentation practices within provider workflows. This role engages directly with providers to identify barriers, refine workflows, enhance EHR tools, and support adoption of efficient documentation practices. The Clinical Specialist also partners with CDI, coding, physician advisors, informatics, analytics, and revenue cycle leaders to ensure that documentation expectations remain clinically relevant, operationally practical, and aligned with coding and reimbursement requirements.
Primary Responsibilities
Independent Clinical Assessment of Documentation:
- Performs independent clinical evaluation of patient records to determine whether documentation accurately reflects diagnostic reasoning, treatment decisions, severity of illness, risk adjustment conditions, and medical necessity.
- Applies advanced practice clinical judgment to identify missed diagnoses, evolving conditions, treatment implications, and documentation gaps not readily identifiable through coding review alone.
- Serves as the clinical authority for complex documentation scenarios requiring provider-level interpretation of patient care.
Provider-to-Provider Clinical Consultation:
- Provides peer-level consultation to physicians and APPs regarding clinical documentation, diagnostic specificity, medical necessity, and documentation supporting professional billing services.
- Facilitates provider-to-provider discussions regarding clinical rationale and documentation practices in complex or disputed cases.
Documentation Impact on Clinical Care Delivery:
- Evaluates how documentation workflows impact patient care delivery, care coordination, treatment planning, and clinical decision-making.
- Recommends and validates documentation workflow changes based on direct clinical practice expertise and current standards of care.
Clinical Governance and Policy Authority:
- Serves as a clinical representative on documentation governance committees.
- Reviews and approves clinical documentation standards, educational content, and workflow recommendations requiring advanced clinical expertise.
- Advises CDI leadership, physician advisors, and operational leaders regarding clinical implications of documentation policies
Advanced Medical Necessity and Denial Prevention:
- Performs advanced review of chronic condition documentation and risk adjustment accuracy utilizing provider-level clinical assessment.
- Validates clinical appropriateness of HCC capture opportunities and diagnostic specificity recommendations.
Population Health / Risk Adjustment Expertise:
- Conducts clinical validation reviews requiring advanced provider-level assessment of diagnoses, treatment plans, and medical necessity.
- Partners with physician advisors and providers to address complex clinical denials and documentation disputes.
- Provides clinical support for appeals involving determination of diagnosis validity, treatment appropriateness, and documentation integrity.
Provider Engagement & Workflow Integration:
- Conduct provider-to-provider assessment of clinical workflow barriers impacting documentation integrity, medical necessity capture, and diagnostic specificity.
- Serve as an APP liaison to physicians and APPs to evaluate workflow changes through the lens of direct patient care delivery.
EHR Optimization & Documentation Tools:
- Provide clinical approval and validation of provider documentation tools, templates, prompts, and workflow designs to ensure alignment with clinical practice standards and provider workflow realities
- Partner with IT, informatics, and operational teams to implement solutions that improve efficiency while supporting accurate capture of patient acuity, medical decision making, and work effort.
- Evaluate effectiveness of documentation tools and recommend enhancements based on provider feedback and data.
CDI Strategy & Interdisciplinary Collaboration:
- Serve as the clinical workflow expert within the CDI team and serves as the designated APP clinical subject matter expert for enterprise documentation initiatives requiring provider-level clinical assessment, medical necessity expertise, and clinical practice interpretation
- Collaborate with physician advisors, reimbursement leaders, analysts, and operational stakeholders to align documentation improvement with clinical realities and financial goals.
- Support targeted educational initiatives and workflow change management across service lines or departments.
Knowledge – Skills – Abilities
- Strong knowledge of clinical workflows, provider documentation practices, pathophysiology, and medical decision making principles.
- Understanding of professional billing documentation requirements and the impact of workflow design on documentation quality and coding outcomes.
- Ability to translate coding and regulatory requirements into practical clinical workflow solutions.
- Strong interpersonal, facilitation, and change-management skills.
- Ability to educate both providers and non-clinical stakeholders on clinical concepts and documentation practices.
- Proficiency in EHR systems (EPIC preferred) and Microsoft Office tools.
Qualifications
Appropriate experience may be substituted on equivalent basis.
Minimum Required Education: Master's or Doctoral degree in nursing or other applicable advanced practice discipline
Minimum Required Experience: 5 years of Recent clinical practice experience required.
Preferred Experience: Experience working in ambulatory, professional billing, or provider-facing documentation environments preferred. Experience with EHR optimization, workflow redesign, education, or clinical informatics strongly preferred.
Required Certification/Licensure(s): Active Advanced Practice Provider license/certification consistent with organizational requirements (for example, Nurse Practitioner/APNP; other APP credentials may be considered if aligned with the role design).
Preferred Certification/Licensure(s): Knowledge of CDI, coding, informatics, or documentation improvement principles; coding/CDI certification is a plus.
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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.
