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
Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers.
Benefits
The health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees 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.