[Hiring] Clinical Documentation Specialist @University Hospitals

Role Description

The Professional Fee Clinical Documentation Specialist (CDS) will serve as an advisor and expert resource for providers to improve the accuracy of clinical documentation to support patient complexity, risk profiles and appropriate E/M levels thereby supporting the provider's efforts and their professional fee billing. The CDS primarily assists providers in identifying clinically relevant information and capturing the clinical documentation needed to accurately reflect patient acuity.

• Focus on recapture and identification of chronic conditions reflected in Hierarchical Condition Categories (HCCs), impacting the patient risk adjusted profile (RAF score).
• Assist with highlighting opportunities based on the provider's medical decision making to appropriately reflect the level of service provided for patient care.
• Responsible for completing pre-visit and post-claim reviews.
• Provide clear communication and education to providers on their documentation, coding and billing practices, adhering to compliance standards set by governing entities such as CMS, AHA, etc.
• Pre-visit reviews identify documentation opportunities for recapturing previously documented HCC diagnoses or new suspect conditions.
• Post-claim reviews focus on E/M encounters and highlight opportunities based on a provider's medical decision making and the patient's acuity.
• Coordinate with colleagues from the CDI Program regarding education and training to improve clinical documentation based on findings from reviews.

Qualifications

• High School Equivalent / GED (Required)
• Associate's Degree (Preferred)

Requirements

• 3+ years Coding and/or clinical documentation integrity (Required)
• Extensive clinical knowledge and understanding of pathophysiology (Required proficiency)
• Strong critical thinking skills and utilization of clinical knowledge to identify potential clinical indicators (Required proficiency)
• Excellent written and verbal communication skills (Required proficiency)
• Strong project management skills (Required proficiency)
• Strong interpersonal skills, with demonstrated success at communicating effectively (Required proficiency)
• Ability to work independently in a time-oriented environment (Required proficiency)
• Demonstrates skilled ability and comfort with electronic medical records (EPIC preferred) (Required proficiency)
• Proficient with personal computer applications (Excel, Word, and Power Point) (Required proficiency)
• Ability to build education material that is meaningful for providers and team members (Required proficiency)
• Strong problem solving and investigative skills (Required proficiency)

Benefits

• Maintains strict confidentiality of all patients, employee and physician information according to HIPAA guidelines.
• Seeks out opportunities for individual growth and development, including attending various meetings, conferences, courses, seeking certifications, as required.
• Uses tact and sensitivity when communicating with patients, visitors, co-workers, and other personnel.
• Serves on department and/or institutional committees as requested.
• Performs other duties as assigned.
• Complies with all policies and standards.

Licenses and Certifications

• Certified Coding Specialist (CCS) (Required) or Certified Professional Coder (CPC) or CRC, or other coding or CDI credential (Required)
• Registered Nurse (RN), Ohio and/or Multi State Compact License (Preferred)
• Licensed Practical Nurse (LPN), Ohio and/or Multi State Compact License (Preferred)

Physical Demands

• Standing: Occasionally
• Walking: Occasionally
• Sitting: Constantly
• Lifting: Rarely up to 20 lbs
• Carrying: Rarely up to 20 lbs
• Pushing: Rarely up to 20 lbs
• Pulling: Rarely up to 20 lbs
• Climbing: Rarely up to 20 lbs
• Balancing: Rarely
• Stooping: Rarely
• Kneeling: Rarely
• Crouching: Rarely
• Crawling: Rarely
• Reaching: Rarely
• Handling: Occasionally
• Grasping: Occasionally
• Feeling: Rarely
• Talking: Constantly
• Hearing: Constantly
• Repetitive Motions: Frequently
• Eye/Hand/Foot Coordination: Frequently

Travel Requirements

• 10%25