Clinical Documentation Spec

Job Opening ID

257937

Working Title

Clinical Documentation Spec

Job Title

Clinical Documentation Spec

Work Location

Michigan Medicine - Ann Arbor

Ann Arbor, MI

Modes of Work

Hybrid

Full/Part Time

Full-Time

Regular/Temporary

Regular

FLSA Status

Exempt

Organizational Group

Exec Vp Med Affairs

Department

MM Rev Cycle (PTO)

Posting Begin/End Date

12/16/2024 - 1/01/2025

Career Interest

Healthcare Admin & Support

Job Summary

The Clinical Documentation Specialist (CDS) is responsible for applying their knowledge of medical terminology, risk adjustment, and coding to ensure appropriate capture of diagnoses based on coding guidelines and identify gaps and opportunities within ambulatory settings. They are responsible for planning, coordinating, and providing education to faculty, APPs, and house officers related to Hierarchical Condition Categories (HCC). Develop and implement an education plan to communicate the principles and importance of accurate and complete documentation within the electronic health record (EHR). Serve as a resource of documentation guidelines and regulatory requirements and updates. Partner with and maintain strong collaborative relationships with the Medical Director, Physician Champions, UMMG Department Clinical Documentation Specialists (CDS), and Revenue Quality Liaisons (RQL). Understand and articulate data and analysis clinical documentation and risk adjustment coding trends.

Mission Statement

Michigan Medicine improves the health of patients, populations and communities through excellence in education, patient care, community service, research and technology development, and through leadership activities in Michigan, nationally and internationally. Our mission is guided by our Strategic Principles and has three critical components; patient care, education and research that together enhance our contribution to society.

Responsibilities*

Core Responsibilities and Expectations:

• Responsible for Hierarchical Condition Category (HCC) pre-visit and post-visit reviews and makes corrections when needed to ensure appropriate diagnoses are captured based on coding guidelines.
• Assists providers with effective documentation and accurate coding.
• Serves as a source of contact and resource for faculty, APPs, and house officers regarding clinical documentation and medical coding for patient care services.
• Prepares reports to provide feedback on provider performance including HCC documentation and coding.
• Identifies HCC pre-visit and post-visit 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 power point presentations to be shared at department meetings, as requested.
• Serves as a resource on documentation requirements and ensure compliance with applicable laws and regulations.
• Partners with the RQL 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

Department Specific Responsibilities and Expectations:

• Responsible for Hierarchical Condition Category (HCC) pre-visit and post-visit reviews and makes corrections when needed to ensure appropriate diagnoses are captured based on coding guidelines.
• Conduct special review requests to assess compliance risk and identify areas of opportunities for improvement in coding and billing practices. Conduct post-review group and individual training and education.
• Develop and present issue-specific and general revenue cycle presentations to large groups, including faculty meetings, provider orientation sessions, etc.
• Onboard new faculty and advance practice providers with compliance training via on-line training tools.
• Research, interpret and communicate applicable laws and regulations, and third-party payer rules.
• Keep providers informed of rapidly changing regulatory and third-party payer billing rules; serve as a liaison with the clinical departments in the areas of coding and documentation for their specialties.
• Perform focused analytical documentation and coding reviews to proactively assess compliance and revenue loss risks for areas of concern identified by the Revenue Cycle Compliance and Education office.
• Participate in management of the Revenue Cycle compliance work plans, including identifying and assessing issues that create risk for the Health System.
• Collaboration with the Health Information Management (HIM) team on joint projects related to quality measures and best practices in documentation impacting both facility and professional billing.

Required Qualifications*

• Associate degree or equivalent
• At least five years of medical coding experience
• Current RHIT, RHIA, CPC, or CRC certification
• Demonstrated experience providing clinical documentation and coding education to providers.
• Excellent communication skills (verbal and written) to enable effective outcomes with the 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, 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-changing 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, innovating and out-of-the-box thinking.
• This is a Hybrid/Remote position

Desired Qualifications*

• Bachelor's degree in health information management or other healthcare related field.
• Knowledge of HCC coding and Risk Adjustment Credential from AHIMA or AAPC
• Demonstrated understanding of Evaluation and Management (E&M), Surgery and Minor procedure coding, billing, and documentation
• Certification in healthcare compliance through Healthcare Compliance Association (HCCA).
• Experience performing reviews, analyzing documentation, and identifying areas of risk and potential irregularities across the revenue cycle.
• Experience interpreting and applying CMS and other third-party payer guidelines and regulations, particularly related to professional services and teaching physician rules.
• Ability to communicate complex policies and regulations to multiple audiences.

Modes of Work

Positions that are eligible for hybrid or mobile/remote work mode are at the discretion of the hiring department. Work agreements are reviewed annually at a minimum and are subject to change at any time, and for any reason, throughout the course of employment. Learn more about the work modes .

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.