Clinical Documentation Specialist Outpatient

Corewell Health • Southfield, MI

5d • Onsite

About The Position

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). 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.

Requirements

• 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

Responsibilities

• 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.

Benefits

• Comprehensive benefits package to meet your financial, health, and work/life balance goals.
• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level