Outpatient Cln Documentation Spec Nurse

J  o  b    D  e  s  c  r  i  p  t  i  o  n

JOB INFORMATION

Effective Date:

9/16/2024

Entity:

Wisconsin

Job Code:

300131

Job Title:

Outpatient Cln Documentation Spec Nurse

FLSA Exemption Status:

Exempt

Management Level:

Individual Contributor

JOB SUMMARY

The Outpatient Clinical Documentation Specialist Nurse (OPCDS -RN) working under the direction of the Supervisor, is an advisor to ambulatory clinicians regarding complete and accurate outpatient documentation, specificity surrounding Hierarchical Condition Categories (HCCs) through concurrent, prospective, and retrospective evaluation and assimilation of the objective and subjective data documented within the medical record. The outcome will be documentation that accurately and completely captures the clinical picture, severity of illness,  and complexity of the patient while providing specific and complete information to be utilized in coding, profiling, and, outcomes of the reporting for both the facility and the physicians. The OPCDS utilizes knowledge of official coding guidelines (ICD-10 and CPT), Hierarchical Condition Categories (HCC), and AHIMA/ACDIS physician query brief. The Specialist functions as an expert source for information regarding the impact of documentation on patient care, quality metrics, Hierarchical Condition Categories (HCCs), and correct reimbursement. The incumbent functions as a liaison between ambulatory clinicians and outpatient coders with the goal of creating mutual understanding of the many uses of medical record documentation.

ESSENTIAL DUTIES

•

Review documentation available in the Medical Record to facilitate workflows that support the clinical picture/severity of illness/complexity of the patient care rendered to patients.

•

Utilize available encoder, grouper software, and other coding resources to determine the appropriate ICD-10-CM, CPT, and/or HCPCS.

•

Uses clinical knowledge to identify potential clarifications of the record.

•

Concurrently, prospectively & retrospectively reviews medical records to identify unclear, ambiguous or inconsistent documentation by initiating documentation clarifications in the EMR for conflicting diagnosis, further specificity in diagnosis/procedure codes and ensuring completeness of the medical record.

•

Collaborates with nursing or coding staff on retrospective medical record review for severity, accuracy and quality issues.

•

Ensure documentation in the medical record follows the official coding guidelines, internal guidelines and AHIMA/ACDIS physician query brief.

•

Create and analyze reports for documentation improvement trending and high-level dashboards for ongoing monitoring and opportunities.

•

Provide ongoing feedback to physicians and other providers regarding coding guidelines and requirements. Assist with educational in-services for physicians, other providers, and clinic staff relating to clinical documentation compliance as well as new policies and procedures related to billing.

As needed, additional responsibilities reasonably within the scope of duties and physical requirements may be assigned.  ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS AND RESPECT FOR PEOPLE COMMITTMENTS.

X

Non-Clinical

JOB REQUIREMENTS

Associate's Degree

in Nursing

Required

Bachelor's Degree

in Nursing

Preferred

3 years

of nursing, case management, utilization review or quality resources experience in an acute care or ambulatory setting

Required

3 years

of Clinical Documentation Integrity experience highly desirable

Preferred

5 years

of nursing, case management, utilization review, or quality resources experience in an acute care setting

Preferred

Licensed as a Registered Nurse (RN) in the State of WI or holds a license issued by a jurisdiction that has adopted the nurse licensure compact

Upon Hire

Required

Certified Clinical Documentation Specialist

Preferred

LICENSE, CERTIFICATIONS, AND REGISTRATIONS MUST BE MAINTAINED PER UW HEALTH POLICY. 

•

Willing to work as a team – innovation and collaboration is a priority

•

Experience with an Electronic Medical Record (EMR)

•

Knowledge of, but not limited to, current coding guidelines and methodologies: HCCs, ICD-10-CM coding guidelines and conventions

•

Extensive knowledge of medical terminology, anatomy and pathophysiology, pharmacology and ancillary test results

•

Strong organization and analytical thinking skills – detail oriented

•

Proficient with Microsoft Office applications (Outlook, Word, Excel)

•

Demonstrates critical thinking skills, able to assess, evaluate, and teach

•

Self-motivated and able to work independently without close supervision

•

Strong communication skills (interpersonal, verbal and written)

•

Familiarity with the external reporting aspects of healthcare

•

Familiarity with the business aspects of healthcare, including prospective payment systems

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

☒

Sedentary: Ability to lift up to 10 pounds maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and small tools. Although a sedentary job is defined as one, which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Up to 10#

Negligible

Negligible

☐

Light: Ability to lift up to 20 pounds maximum with frequent lifting and/or carrying of objects weighing up to 10 pounds. Even though the weight lifted may only be negligible amount, a job is in this category when it requires walking or standing to a significant degree.

up to 20#

Up to 10# or requires significant walking or standing or requires pushing/pulling of arm/leg controls.

Negligible or constant push/pull of items of negligible weight

☐

Medium: Ability to lift up to 50 pounds maximum with frequent lifting and/or carrying objects weighing up to 25 pounds.

20-50#

10-25#

Negligible-10#

☐

Heavy: Ability to lift up to 100 pounds maximum with frequent lifting and/or carrying objects weighing up to 50 pounds.

50-100#

25-50#

10-20#

☐

Very Heavy: Ability to lift over 100 pounds with frequent lifting and/or carrying objects weighing over 50 pounds.

Over 100#

Over 50#

Over 20#

Other - list any other physical requirements or bona fide occupational qualifications not indicated above:

Over 50 lbs.

UW Health does not require, nor does it expect that its employees lift more than 50 lbs unassisted. Objects in excess of 50 lbs should be lifted or moved with mechanical means or through a team lift. Employees in patient care areas are expected to utilize mechanical lifts and adhere to the "Use of Mechanical Lifts (Liko)" policy in the Patient Services Policy and Procedure Manual.

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.

THE EMPLOYEE MUST BE ABLE TO COMPLETE ALL PHYSICAL REQUIREMENTS OF THE JOB WITH OR WITHOUT AN APPROVED ACCOMODATION. Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.