Job Information
MCW: SARGEANT HEALTH CENTER Clinical Documentation Specialist in MILWAUKEE, Wisconsin
JOB REQUIREMENTS: Position Description: Every day, in ways both big and small, the Medical College of Wisconsin (MCW) is impacting lives for the better. MCW ... changemaking for a healthier Wisconsin. The Clinical Documentation Specialist (CDS) is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record. This position will be responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the acuity and severity of illness of the patient, as well as the level of services and procedures rendered. The CDS assesses clinical documentation through extensive review of the medical record, interaction with physicians, advanced practice providers, ancillary clinical staff, and coding specialists, to ensure that appropriate reimbursement is received for the patient care services rendered, and the clinical information utilized in profiling and reporting outcomes is complete and accurate. Responsibilities: Facilitates appropriate clinical documentation to support appropriate assignment of CPT/HCPCS and ICD-10-CM codes, as well as pertinent modifiers. Analyzes clinical status of patient, current treatment plan, past medical history and identifies potential gaps in provider documentation. Communicates with providers verbally or through written or electronic methodology to validate observations and if appropriate, query for more specific documentation and/or diagnoses via concurrent query process guidelines. Applies clinical knowledge and expertise to accomplish optimal identification of patient\'s condition in the medical record. Participate in and take an active role in the identification, management, and development of Epic enhancements regarding clinician documentation and billing, including alignment of clinical documentation with coding rules and guidelines. Collaborate closely with providers and end-users to understand their operational needs and workflows, serving as a key liaison for Epic clinical documentation enhancements and training needs. Provide training to coding/charge capture and billing office staff on updates to Epic clinical documentation workflows and processes. Maintain up to date knowledge of EPIC as needed to support the implementation of changes needed. Collaborate with revenue integrity, coding, and billing office staff to promote complete and accurate clinical documentation and correct negative trends. Displays leadership and accountability, serving as a coach and role model. Communicates effectively, timely and in an open, honest manner. Shares knowledge... For full info follow application link. EEO/AA Minorities/Females/Vets/Disability The Medical College of Wisconsin is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, veteran status, disability or sexual orientation. ***** APPLICATION INSTRUCTIONS: Apply Online: ipc.us/t/1D86677D13814B28 Qualified females, minorities, and special disabled veterans and other veterans are encouraged to apply.