Clinical Documentation Spec

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Summary

The Clinical Documentation Specialist (CDS) is responsible for planning, coordinating and providing education to faculty, APPs, and house officers related to clinical documentation improvement and clinical revenue optimization for section of General Surgery and the UMMG.  Apply their 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 departments Physician Champion 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/house officer 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).    

Responsibilities*

  • Serves as the primary source of contact and resource for faculty, APPs, and house officers with regard to clinical documentation and medical coding for patient care services
  • Develops tools 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 to allow for clinician education
  • Provides group and one-on-one education for faculty, APPs, and house officers, as needed
  • Prepares case and specialty specific documentation examples and PowerPoint presentations to be shared at department meetings
  • Analyzes data to prioritize areas of RVU 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 patients, faculty, and staff
  • Performs other duties appropriate to the CDS function, as assigned

Required Qualifications*

  • At least five years of medical coding experience 
  • Current RHIT, RHIA or CPC certification
  • 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 navigate the EHR to identify documents for review to provide accurate capture of clinical information.
  • Extensive CPT and ICD-10 coding knowledge
  • Medical terminology and clinical knowledge with the ability to review documentation and determine what documentation is needed to provide accurate medical codes
  • 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.
  • Proficiency in computer use including Microsoft Office Suite experience
  • Provide support to clinicians on navigating the EHR to make addendums, create SmartTexts and SmartPhrases and utilize templates
  • 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

Additional Information

Supervision:
The CDS will be supervised by the Chief Department Administrator or designee. 
The CDS does not have supervisory responsibilities.

Background Screening

Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings.  Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.

Application Deadline

Job openings are posted for a minimum of seven calendar days.  The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled anytime after the minimum posting period has ended.

U-M EEO/AA Statement

The University of Michigan is an equal opportunity/affirmative action employer.