Group Clinical Documentation & Denial Prevention Specialist - Full time (HYBRID)

About the Role

We’re looking for a strategic leader to bridge the gap between high-quality patient care and accurate medical reporting. In this role, you’ll be the architect of a more resilient, compliant, and efficient healthcare system.

Responsibilities

• Perform daily deep-dives into medical records to ensure the severity of illness and intensity of services are captured with clinical integrity.
• Analyze clinical status and treatment plans to proactively resolve ambiguities, drastically reducing denials through advocacy and process improvement.
• Develop and lead documentation training programs for all medical staff, transforming complex compliance requirements into actionable knowledge.
• Partner with the Medical Records and Utilization Management committees, providing data-driven insights and statistics to steer hospital-wide quality assurance.
• Implement sophisticated workflows that ensure every patient’s story is told accurately, securing the resources they need for recovery.
• Perform thorough daily review of medical records to ensure they accurately reflect the level of care provided and compliance with medical necessity documentation requirements.
• Analyze the medical record regarding the clinical status of patient, current treatment plan, and past medical history; seek clarification of incomplete, unclear, and ambiguous documentation.
• Develop and implement plans for both formal and informal education of attending providers, nursing, social workers, and other clinical staff.
• Provide education and training to staff on clinical documentation best practices and medical necessity criteria.
• Collaborate with attending providers to ensure clinical information is accurately and comprehensively documented.
• Intervene with clinical and medical staff to ensure documentation supports applicable diagnoses.
• Provide education to providers and other clinicians on compliant documentation practices to support medical necessity, severity, reimbursement, and continuity of patient care.

Requirements

• A keen clinical eye capable of synthesizing lab results, diagnostic data, and provider notes into a cohesive medical narrative.
• Expertise to navigate Utilization Management standards and medical necessity requirements.
• A collaborative spirit ready to mentor multidisciplinary teams on documentation best practices.

Qualifications

• Education: BS in Nursing or Masters degree in Social Work or Psychology.
• Experience: Minimum three years of clinical experience in a hospital setting. At least one year of experience in Utilization Management or knowledge of Medicare, Medicaid, and Managed Care preferred.
• License: LCPC, LCSW, or RN preferred.
• Knowledge: Utilization review, insurance, and managed care procedures. Comprehensive understanding of medical necessity criteria (InterQual, MCG, CALOCUS, LOCUS, ASAM) for acute inpatient behavioral health. Knowledgeable in behavioral health managed care and clinical assessment skills to align patient acuity with level of care practice guidelines (DSM-V). Knowledge of DSM, ICD-10, and clinical best practices for treatment of medical, mental health, and chemical dependency diagnoses across all age spans. Effective oral and written communication skills. Current knowledge of regulating/accrediting agency guidelines. Basic knowledge of computer skills and statistical analysis desired.

Benefits

• A rewarding career improving the lives of youth and adults.
• Resources of a large health system (UHS, Inc.).
• An engaged leadership team.
• A commitment to patient safety.
• Career advancement and mobility.
• Competitive compensation and benefits package, including a sign-on bonus.

Working Conditions

• General hospital environment.
• Sedentary work with occasional lifting required.
• Important physical capabilities: bending, reaching, standing, listening, verbal skills, pushing, walking, and repetitive typing/keying.
• Must be able to use computer, printer, typewriter, and office supplies.

Reasonable accommodations may be made to enable individuals with disabilities to perform the primary functions.