Job Summary:  The Clinical Documentation and Denial Specialist will assist with development and execution of a planned, systemic, system-wide approach to process design and performance measurement, assessment, improvement, and reporting. Perform data collection and analysis, trend identification for assigned clinical outcomes, and present this data at the appropriate meetings as defined or needed. Serve as team member or facilitator, responsible for promoting and monitoring safe, high-quality, cost-effective healthcare with the best clinical outcomes possible. Provide physician and nurse education to achieve compliance with best practice and evidence-based guidelines. Facilitate interdisciplinary collaboration to measure and assess processes and outcomes, and proactively identify potential solutions with the multidisciplinary team and appropriate service line leaders and directors. Gather and disseminate clinical performance improvement information and quality initiatives to the service lines, hospital and medical staff departments and committees. Assist with retrospective reviews and preparation of appeals as indicated. Facilitate peer review activities and integrate review findings with the credentialing and reappointment process as needed. Working closely and having frequent communication with Service Line Medical Directors, Service Line Directors, and Department Heads will be required. Frequent communication and updates with the Manager and Director are required. This position will require leading meetings, analysis of data, and collaboration with a multidisciplinary team for performance improvement activities. This is a split role between CDS workflow and DRG Denial Management and Appeals based on departmental needs.   

The Clinical Documentation and Denial Specialist is responsible for assisting the denial coordinator with management of client DRG denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. Where warranted, the Appeals Specialist will write sound, compelling factual arguments to recoup revenue. This position also facilitates collaboration between the Utilization Review Specialist’s, Coding staff, HIM staff, CDI staff, Medical Staff, Physician Advisor, Nursing staff, Commercial Payers, VA, Managed Medicare Organizations, Medicare, and Medicaid (Center for Medicare/Medicaid Services) to ensure that any DRG denial is thoroughly reviewed and that an appeal letter, if warranted, is well written and submitted in a timely manner.  In addition, the following are essential duties and responsibilities of the CDS and Denial Specialist:  Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why DRG cases are denied and whether an appeal is warranted.  Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted.  Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical coding references and/or regulatory arguments.  Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable. Work with Clinical Documentation Denials Coordinator to report documentation trends, level of care decisions, and CDI coding issues with CDI Director and Manager, physicians, and other appropriate staff. Ensure compliance with HIPAA regulations, to include confidentiality, as required. Other duties as assigned. CDS and Denial Specialist will work collaboratively with Health Information Management, Utilization Review and Clinical Documentation Specialist to mitigate coding denials. This position is for CaroMont Health care system. Remote work may be approved per Manager/Director discretion with VP sign off. Days and times are subject to Manager/Director discretion, organizational needs, and work performance. Employees must have a personal computer, complete Teleworking CBL as required, and review/sign the corporate Teleworking agreement see (Teleworking policy 15169), and the Remote Access Policy CDI Inpatient (15146).

Qualifications:  MSN preferred/BSN required. Current RN license to practice in NC (NC license or multi-state (compact) license). Five (5) years recent nursing experience required, hospital setting with acute care experience strongly preferred. Requires strong, broad-based clinical knowledge & the understanding of pathology/physiology, analytical thinking, problem solving, plus good verbal and written communication. Strongly encouraged to obtain certification (CCDS) after 2 years in the role. 

EOE AA M/F/Vet/Disability