Clinical Documentation Specialist

2 weeks ago


Wauwatosa, Wisconsin, United States Medix™ Full time
Clinical Documentation Specialist Job Description

We are seeking a skilled Clinical Documentation Specialist to join our team at Medix™. As a Clinical Documentation Specialist, you will play a critical role in ensuring the accuracy and completeness of clinical documentation in the medical record.

Key Responsibilities:
  • Facilitate appropriate clinical documentation to support accurate assignment of CPT/HCPCS and ICD-10-CM codes.
  • Analyze clinical status of patients, current treatment plans, and past medical histories to identify potential gaps in provider documentation.
  • Communicate with providers to validate observations and query for more specific documentation and/or diagnoses via concurrent query process guidelines.
  • Participate in the identification, management, and development of Epic enhancements regarding clinician documentation and billing.
  • Collaborate with providers and end-users to understand their operational needs and workflows.
  • 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 to support the implementation of changes needed.
  • Collaborate with revenue integrity, coding, and billing office staff to promote complete and accurate clinical documentation.
Requirements:
  • Nursing background (Associates or Bachelors Degree)
  • LPN or BSN
  • Coding Certification (CCDS or CDIP preferred)
  • Understanding of CPT, E/M, and 2023 guidelines
  • EPIC Experience
Preferred Qualifications:
  • CCDS and BSN
  • Variety in Coding/Clinical Background

This is a challenging and rewarding role that requires strong leadership and interpersonal skills, as well as excellent written and oral communication skills. If you are a motivated and detail-oriented individual with a passion for clinical documentation, we encourage you to apply for this exciting opportunity.



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