Shift: Mon to Fri 8am - 4:30pm, looking for someone that is flexible to early mornings or working past 4:30pm if needed
Onsite role in Wauwatosa WI 4-5 days a week
Qualifications:
Nursing background (Associates or Bachelors Degree)
LPN OR BSN
Coding Certification (CCDS or CDIP preferred) CPC
Understanding of CPT, E/M and 2023 guidelines
EPIC Experience
Nice to Have Skills:
CCDS & BSN
Variety in Coding / Clinical Background
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.
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.
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