Clinical Documentation Specialist Outpatient
About the Role
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).
Responsibilities
- 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 in 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.
Qualifications
One of the following credentials required upon hire:
- LIC-Registered Nurse (RN) - State of Michigan
- CRT-Coding Specialist (CCS) - AHIMA (American Health Information Management Association)
- CRT-Registered Health Information Technician (RHIT) - AHIMA (American Health Information Management Association)
- CRT-Registered Health Information Administrator (RHIA) - AHIMA (American Health Information Management Association)
- CRT-Professional Coder, Certified - Hospital Outpatient (CPC-H)
- CRT-Outpatient Coder, Certified (COC)
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 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.
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 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.
Schedule
- 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
Primary Location: SITE - Corewell Health Southfield Center - 26901 Beaumont Blvd, Department: Risk Adjustment CDI - Corporate