Clinical APNP Specialist - MCW Medical Group at Medical College of Wisconsin

Job description

Summary The Professional Billing CDI Clinical Specialist is an advanced practice provider role responsible for optimizing documentation practices within provider workflows. This role engages directly with providers to identify barriers, refine workflows, enhance EHR tools, and support adoption of efficient documentation practices. The Clinical Specialist also partners with CDI, coding, physician advisors, informatics, analytics, and revenue cycle leaders to ensure that documentation expectations remain clinically relevant, operationally practical, and aligned with coding and reimbursement requirements. Primary Responsibilities Independent Clinical Assessment of Documentation: Performs independent clinical evaluation of patient records to determine whether documentation accurately reflects diagnostic reasoning, treatment decisions, severity of illness, risk adjustment conditions, and medical necessity. Applies advanced practice clinical judgment to identify missed diagnoses, evolving conditions, treatment implications, and documentation gaps not readily identifiable through coding review alone. Serves as the clinical authority for complex documentation scenarios requiring provider-level interpretation of patient care. Provider-to-Provider Clinical Consultation: Provides peer-level consultation to physicians and APPs regarding clinical documentation, diagnostic specificity, medical necessity, and documentation supporting professional billing services. Facilitates provider-to-provider discussions regarding clinical rationale and documentation practices in complex or disputed cases. Documentation Impact on Clinical Care Delivery: Evaluates how documentation workflows impact patient care delivery, care coordination, treatment planning, and clinical decision-making. Recommends and validates documentation workflow changes based on direct clinical practice expertise and current standards of care. Clinical Governance and Policy Authority: Serves as a clinical representative on documentation governance committees. Reviews and approves clinical documentation standards, educational content, and workflow recommendations requiring advanced clinical expertise. Advises CDI leadership, physician advisors, and operational leaders regarding clinical implications of documentation policies Advanced Medical Necessity and Denial Prevention: Performs advanced review of chronic condition documentation and risk adjustment accuracy utilizing provider-level clinical assessment. Validates clinical appropriateness of HCC capture opportunities and diagnostic specificity recommendations. Population Health / Risk Adjustment Expertise: Conducts clinical validation reviews requiring advanced provider-level assessment of diagnoses, treatment plans, and medical necessity. Partners with physician advisors and providers to address complex clinical denials and documentation disputes. Provides clinical support for appeals involving determination of diagnosis validity, treatment appropriateness, and documentation integrity. Provider Engagement & Workflow Integration: Conduct provider-to-provider assessment of clinical workflow barriers impacting documentation integrity, medical necessity capture, and diagnostic specificity. Serve as an APP liaison to physicians and APPs to evaluate workflow changes through the lens of direct patient care delivery. EHR Optimization & Documentation Tools: Provide clinical approval and validation of provider documentation tools, templates, prompts, and workflow designs to ensure alignment with clinical practice standards and provider workflow realities Partner with IT, informatics, and operational teams to implement solutions that improve efficiency while supporting accurate capture of patient acuity, medical decision making, and work effort. Evaluate effectiveness of documentation tools and recommend enhancements based on provider feedback and data. CDI Strategy & Interdisciplinary Collaboration: Serve as the clinical workflow expert wi