Clinical Documentation Specialist Outpatient

 Posted an hour ago
     
5-10 years experience
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AI Summary

The Clinical Documentation Specialist works with providers to ensure the accuracy, specificity, and completeness of clinical documentation in the ambulatory setting. They evaluate medical records, lab results, and treatment plans to support appropriate diagnosis coding and revenue cycle integrity.

Job Summary

Identifies factors influencing the complexity and severity of patient diagnoses. Works collaboratively with providers in the ambulatory setting to ensure overall specificity, accuracy and completeness of clinical documentation to support the highest integrity of the medical record. Reports to the Manager of Outpatient Clinical Documentation Integrity (CDI).

Essential Functions

  • Utilizes clinical and/or coding expertise, clinical documentation integrity practices and facility specific tools for best practice and compliance with the mission and vision of revenue cycle.

  • Provides daily evaluation of documentation by the Medical Staff and healthcare team including lab results, diagnostic information and treatment plans to assure appropriate documentation supports reported diagnoses.

  • Reviews and makes recommendations for improvement to the overall quality, integrity and completeness of clinical documentation by utilizing knowledge of ICD-10 and CMS guidelines, compliance, policies and procedures.

  • Partners with the CDI Outpatient team members to guide, support and sponsor the CDI Program

  • Communicates with ambulatory providers and healthcare team members to clarify documentation necessary for complete and accurate coding for proper reimbursement via electronic query practices.

  • Educates healthcare team about clinical documentation and coding guidelines via presentations, departmental meetings and documentation tips.

  • Licensed Clinical CDS performs medical record reviews to ensure complete documentation and accurate code capture based on Provider performance.

  • Certified Coding CDS performs medical record reviews and assigns final diagnosis codes prior to payer submission.

Qualifications

Required

  • Bachelor's Degree or equivalent nursing, health-related field, and/or business administration (or equivalent work experience).

  • 5 years of relevant experience Minimum 5 years’ experience required in a clinical setting and/or minimum 5 years’ experience in a coding setting.

  • LIC-Registered Nurse (RN) - STATE_MI State of Michigan Upon Hire Or

  • CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association Upon Hire Or

  • CRT-Registered Health Information Technician (RHIT) - AHIMA American Health Information Management Association Upon Hire Or

  • CRT-Registered Health Information Administrator (RHIA) - AHIMA American Health Information Management Association Upon Hire Or

  • CRT-Professional Coder, Certified - Hospital Outpatient (CPC-H) - UNKNOWN Unknown Upon Hire Or

  • CRT-Outpatient Coder, Certified (COC) - UNKNOWN Unknown Upon Hire

    About Corewell Health

    As a team member at Corewell Health, you will play an essential role in delivering personalized health care to our patients, members and our communities. We are committed to cultivating and investing in YOU. Our top-notch teams are comprised of collaborators, leaders and innovators that continue to build on one shared mission statement - to improve health, instill humanity and inspire hope. Join a nationally recognized health system with an ambitious vision of continued advancement and excellence.


    How Corewell Health cares for you

    • Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
    • On-demand pay program powered by Payactiv
    • Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
    • Optional identity theft protection, home and auto insurance
    • Traditional and Roth retirement options with service contribution and match savings
    • Eligibility for benefits is determined by employment type and status

    Primary Location

    SITE - Corewell Health Southfield Center - 26901 Beaumont Blvd

    Department Name

    Risk Adjustment CDI - Corporate

    Employment Type

    Full time

    Shift

    Day (United States of America)

    Weekly Scheduled Hours

    40

    Hours of Work

    8 a.m. to 4:30 p.m.

    Days Worked

    Monday to Friday

    Weekend Frequency

    N/A

    CURRENT COREWELL HEALTH TEAM MEMBERS – Please apply through Find Jobs from your Workday team member account. This career site is for Non-Corewell Health team members only.

    Corewell Health is committed to providing a safe environment for our team members, patients, visitors, and community. We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. We are committed to supporting prospective team members who require reasonable accommodations to participate in the job application process, to perform the essential functions of a job, or to enjoy equal benefits and privileges of employment due to a disability, pregnancy, or sincerely held religious belief.

    Corewell Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

    An interconnected, collaborative culture where all are encouraged to bring their whole selves to work, is vital to the health of our organization. As a health system, we advocate for equity as we care for our patients, our communities, and each other. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do. We invite those that share in our commitment to join our team.

    You may request assistance in completing the application process by calling 616.486.7447.

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