The Outpatient Clinical Documentation Specialist (CDS), in conjunction with physicians, coders, and clinical staff, will utilize documentation and coding expertise to facilitate the quality and completeness of medical record documentation of outpatient encounters, including but not limited to clinic visits, outpatient surgical documentation, emergency department visits, and other ancillary services. Through concurrent, prospective, and retrospective evaluation and assimilation of the medical record along with communication with physicians and other clinicians, the CDS will be responsible for achieving improved documentation results for the organization. The outcome will be documentation that accurately and completely captures the clinical picture/severity of illness/complexity of the patient while providing specific and complete information to be utilized in coding, profiling and outcomes reporting of both the facility and the physicians. The CDS utilizes knowledge of national coding guidelines (ICD-10 and CPT), Hierarchical Condition Categories (HCC), standards of compliance, and clinical knowledge to identify opportunities and to achieve results.
EDUCATION/EXPERIENCE REQUIRED:
- Registered Nurse (RN) CCDS, CDIP, RHIA, RHIT, CPC, CRC, or CCS; or combination thereof.
- If you are an RN and do not have CPC, CRC, or CCS it must be obtained within one year of hire.
- 3 or more years’ experience either in the clinical field (RN), CDI field, (CCDS, CDIP) or coding (RHIA, RHIT, CPC, CRC, CCS) required.
- 1 or more years’ experience in HCC/Risk Adjustment preferred.
- Knowledge of ICD-10 and HCC coding guidelines.
- Exemplary organizational and communication skills.
- Ability to build relationships, negotiate processes and outcomes, and influence behaviors.
- Knowledge of health care fiscal management goals and strategies, including but not limited to trends and issues in health care reimbursement, coding guidelines, and case management.
- Knowledge of electronic medical record systems and demonstrated Microsoft Office competency.
- Ability to withstand pressure of deadlines and receipt of work with variable requirements.
- Ability to work independently, be resourceful, and possess strong organizational skills.
- Ability to communicate effectively to physicians and other clinical staff; be courteous, tactful, and cooperative.
- Ability to use critical thinking and appropriate judgement throughout all phases of work.
CERTIFICATIONS/LICENSURES REQUIRED:
- Registered Nurse (RN) CCDS, CDIP, RHIA, RHIT, CPC, CRC, or CCS; or combination thereof. If you are an RN and do not have CPC, CRC, or CCS it must be obtained within one year of hire.
Additional Details
This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.
Overview
Partnering with nearly 2 million people on their health journey, Henry Ford Health provides a full continuum of services at 250 care locations throughout southeast and south central Michigan. With 33,000 valued team members, Henry Ford is also among Michigan’s largest and most diverse employers. Our superior care and discoveries are powered by nearly 6,000 physicians, researchers and advanced practice providers. Learn more at henryford.com.
Benefits
Whether it’s offering a new medical option, helping you make healthier lifestyle choices or
making the employee enrollment selection experience easier, it’s all about choice. Henry
Ford Health has a new approach for its employee benefits program – My Choice
Rewards. My Choice Rewards is a program as diverse as the people it serves. There are
dozens of options for all of our employees including compensation, benefits, work/life balance
and learning – options that enhance your career and add value to your personal life. As an
employee you are provided access to Retirement Programs, an Employee Assistance Program
(Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness, and a whole host of other benefits and services. Employee’s classified as contingent status are not eligible for benefits.
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is
committed to the hiring, advancement and fair treatment of all individuals without regard to
race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,
weight, marital status, family status, gender identity, sexual orientation, and genetic information,
or any other protected status in accordance with applicable federal and state laws.