Clinical Document Specialist

Metro Health | Wyoming, MI

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Posted Date 9/25/2023

Clinical Document Specialist - Physician Practices * Days - 40hrs/wk

Shift: Days

General Summary:

The UMHP Clinical Documentation Specialist (CDS) is responsible for planning, coordinating and providing education related to clinical documentation improvement and clinical charge capture optimization for the Medical Group service line physicians, APPs and staff. The CDS will improve and optimize workflows and processes in the education, analysis, maintenance and support of charging, coding, documentation, revenue optimization, reimbursement excellence, Annual Wellness Visits (AWVs), prior authorization, modifier usage trends/development, portal messaging and CPT/ICD-10 and HCC code usage for UMHP to achieve best in class. The CDS will apply their knowledge of medical terminology and coding to develop workflows, implement education plans and communicate the principles and importance of accurate and complete documentation to support charging for outpatient professional clinical visits/services, surgeries, procedures and imaging studies. The CDS identifies gaps and opportunities for charge capture and assist with implementation of processes in the ambulatory clinical setting along with the medical and service line leadership. The CDS will understand and articulate data analysis specific to physician and APP clinical documentation, charge capture and revenue activity, provide updates on status and progress of efforts to improve revenue capture and maintain a strong collaborative relationship with the Clinically Integrated Network (CIN) and other relevant departments.


  • Associate degree or equivalent (i.e. medical billing and coding, health information technology/management, health administration, business administration or another related field required).
  • RHIT, RHIA, CCS, CCS-P, CPC or other professional HIM coding certificate.
  • At least three (3) years of medical coding experience and in an educational or training and development setting required.
  • EPIC or Revenue Cycle Certification a plus.
  • 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 or 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 and 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.
  • Possess proactive, strategic, innovating and out-of-the-box thinking.
  • Exhibit an understanding of health care administration, health industry trends, and an understanding of the University of Michigan Health-West organizational structure and mission.
  • Demonstrates attention to detail, consistency, and meets multiple deadlines in a timely manner.
  • Demonstrates leadership, independence, responsibility, accountability and good judgment. Ability to think strategically.
  • Acts as a self-starter and demonstrate a willingness to take on new and challenging leadership roles, as well as non-leadership projects and deliverables.
  • Accepts and respects diversity without judgment.

Essential Functions and Responsibilities:

  1. Assist in the design, implementation, education and evaluation of tools and resources to assist providers with efficient and effective documentation, accurate coding and charge capture opportunities. All coding edits and/or revisions including claim submission are the sole responsibility of the HIM and billing teams. All coding education will be approved by Compliance prior to implementation.
  2. Provides coding and documentation education for physicians and APP’s. Collaborates with the OPWB Associate Clinical Leaders (ACL) of Positive Practice on education efforts.
  3. Develops upstream coding, documentation, charge capture, revenue optimization and reimbursement excellence education approach focused on new departments and emphasizing new specialty areas to increase knowledge and establish sustainable best practices early on.
  4. Assists in onboarding process for physicians and APPs with orientation to documentation, coding and charge capture excellence, establishing a 3-to-9-month check-in/assessment process with all recently onboarded providers ensuring appropriate charge capture check-ins.
  5. Communicates with Primary Medical Group service line leaders, provider champions, physicians and APPs with regard to clinical documentation and medical coding for patient care services.
  6. Prepares and analyzes reports to provide feedback on provider and coding performance including state of documentation, charge capture and reconciliation.
  7. In collaboration with the Lead Revenue Optimization and Reimbursement Excellence Coordinator and ACCCs Revenue Optimization & Reimbursement Excellence, identifies Return on Investment, documentation trends and priority areas/pain points to share with site/service line leadership to allow for clinician education. Prepares case and specific documentation examples/presentations to share at department meetings.
  8. Analyzes data to prioritize areas of wRVU recovery.
  9. Assists with UMHP and department initiatives to improve revenue, centralize outpatient prior authorization processes and reduce avoidable write offs.
  10. Assists with the strategic development of outpatient charge capture optimization (i.e. professional clinical visits/services, surgeries, procedures and imaging studies), and facilitates change processes required.
  11. Performs chart reviews for the purpose of providing feedback to individual providers, ensuring smooth handoffs and follow-up to sites/service lines and consistent communication between all parties.
  12. Identifies educational opportunities to improve and enhance learning. Maintains current with specialty coding updates, work processes, tools, and clinical and administrative applications necessary to perform job functions.
  13. Serves as a resource on documentation requirements and ensures compliance with applicable laws and regulations.
  14. Builds and maintains positive working relationships throughout the organization that enable efficient leadership through projects involving change management or complex cross-departmental collaboration.
  15. Performs other duties as assigned. These may include but are not limited to: Maintaining a current knowledge base of department processes, protocols and procedures, pursuing self-directed learning and continuing education opportunities, and participating on committees, task forces, and work groups as determined by management.

Requisition #: req6525

FTE status: 1

On-call: No

Weekends: No

Job Type
Full time

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