Epic CDI Specialist — Elevate Clinical Documentation

Medical College of Wisconsin; Milwaukee (WI); Hybrid; USD 70,000 - 100,000; Full time

Benefits offered by this job

Health insurance

Retirement plan

Tuition reimbursement

Paid parental leave

Onsite fitness facility

Job summary

Medical College of Wisconsin is seeking a Clinical Documentation Specialist (CDS) to improve the quality and completeness of provider documentation in the medical record. The CDS works with treating providers to ensure documentation reflects patient acuity, care provided, and the procedures rendered.

The role includes reviewing records, querying clinicians when needed, supporting Epic enhancements, training coding staff, and partnering with revenue integrity to ensure accurate coding and

Qualifications

• Bachelor’s degree in healthcare administration, business, IT, health informatics, nursing, or related field.
• Five years’ experience in a similar or relevant CDI/coding role.
• Preferred eight+ years in professional services coding, CDI, or nursing.
• Coding Certifications (CPC, CCS-P, RHIT, RHIA) or CDI/ CCDS/ CCDS-O certifications; or WI Nursing license.

Responsibilities

• Facilitate documentation to support CPT/HCPCS and ICD-10-CM codes and modifiers.
• Analyze patient status, treatment, and history to identify documentation gaps; query clinicians as needed.
• Participate in Epic enhancements related to clinician documentation and billing.
• Collaborate with providers to understand workflows and training needs.
• Provide training to coding/charge capture staff on Epic documentation workflows.
• Maintain up-to-date Epic knowledge to support changes.
• Collaborate with revenue integrity, coding, and billing for accurate documentation and compliant coding.
• Provide 1:1 and small-group education to providers and staff on documentation optimization and compliant coding; develop materials.
• Formulate clarifications to improve diagnoses (POA, HCC) and coding accuracy.
• Use software to collect, track, and report outcomes; maintain data integrity.
• Other duties as assigned.

Skills

Clinical documentation

CPT/HCPCS coding

ICD-10-CM coding

Communication

Leadership

Data analysis

Project coordination

Education

Bachelor's degree in healthcare administration, business, IT, health informatics, nursing, or related field

Tools

EPIC

Job description

Medical College of Wisconsin is seeking a Clinical Documentation Specialist (CDS) to improve the quality and completeness of provider documentation in the medical record. The CDS works with treating providers to ensure documentation reflects patient acuity, care provided, and the procedures rendered.

The role includes reviewing records, querying clinicians when needed, supporting Epic enhancements, training coding staff, and partnering with revenue integrity to ensure accurate coding and