Clinical Revenue Cycle Educator

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The Clinical Revenue Cycle Educator provides leadership, coordination, and delivery of training programs across clinical revenue cycle functions, including CDI, coding, denials and utilization review. This position is responsible for developing educational content, conducting training, facilitating feedback loops, and maintaining staff competency to ensure accuracy, compliance, and efficiency. The Educator plays a critical role in new provider onboarding, ongoing education, internal audits, and supporting enterprise initiatives that improve quality and financial performance.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

2. Must Hold at Least One of the Following Certifications:

• Certified Coding Specialist (CCS) through American Health Information Management Association (AHIMA).

• Certified Clinical Documentation Specialist (CCDS) through Association of Clinical Documentation Integrity Specialists.

• Certified Documentation Improvement Practitioner (CDIP) through American Health Information Management Association (AHIMA).

• Health Care Quality and Management Certification (HCQM) through American Board of Quality Assurance and Utilization Review Physicians.

• Accredited Case Manager (ACM) through American Case Management Association.

• Certified Case Manager (CCM) through Commission for Case Manager Certification.

EXPERIENCE:

1. Two (2) years of experience in inpatient acute care coding, CDI, Denials, Utilization Review, or Appeals.

2. Three (3) years of RN experience in a nursing or clinical role.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; Currently enrolled in a BSN program and BSN completion within three (3) years of hire.

EXPERIENCE:

1. Five (5) years in a hospital revenue cycle role with exposure to multiple functions (coding, CDI, UR).

2. Three (3) years of direct educator/trainer experience designing and delivering clinical or operational training programs.

3. Hands-on experience with appeals, payer communication, and denial prevention strategies.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Design and lead systemwide CDI, coding, UR, and denial management training using data-driven curriculum, competency assessments, and audit outcomes to improve accuracy, compliance, and preventable denials.

2. Provide focused training on DRG/CPT updates, clinical criteria, and payer policies; support onboarding of new providers and hospitals with standardized documentation and utilization expectations.

3. Offer individualized, case-based support to staff and providers, addressing real-time documentation, coding, medical necessity, and appeals questions.

4. Develop concise tip sheets, payer grids, documentation guides, and workflow references that reflect current CMS and payer standards.

5. Equip providers with clear guidance on admission criteria, medical necessity documentation, peer-to-peer expectations, and high-risk payer issues.

7. Monitor query accuracy, status determinations, DRG shifts, downgrades, and overturned denials; ensure findings drive corrective education.

8. Review internal/external audits to identify documentation, coding, or utilization gaps; deliver targeted education based on root causes.

9. Develop a coordinated, enterprise-wide education roadmap aligned with regulatory updates, audit trends, and CRC strategic priorities.

10. Collaborate with UR/CDI/Denials/RI leaders to interpret payer rules and create targeted training that reduces preventable denials.

11. Use insights from ClinIntell, CloudMed, Solventum, and Epic reports to focus education on high-impact conditions, DRGs, and denial patterns.

12. Gather frontline feedback, translate operational challenges into education updates, and ensure consistent cross-facility communication.

13. Develop cross-functional education modules that reinforce LOS optimization, DRG integrity, denial prevention, and Epic workflow standardization.

14. Provide expert guidance to directors, physicians, and executives on documentation integrity, medical necessity, and denial mitigation.

15. Track completion, competency, audit scores, and denial trends to evaluate program impact and refine future education priorities.

16. Deliver concise, data-driven summaries of progress, gaps, and recommendations to CRC leadership and CFO councils.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Must be able to sit for long periods of time.

2. Must have visual and hearing acuity within the normal range.

3. Must have manual dexterity needed to operate computer and office equipment.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

2. May be exposed to standard patient care environment.

3. Visual strain may be encountered in viewing computer screens, spreadsheets, and other written material.

4. May require travel.

SKILLS & ABILILTIES:

1. Advanced knowledge of CDI, coding, UR, and revenue cycle operations.

2. Strong teaching, presentation, and facilitation skills.

3. Skilled in interpreting audit results and translating them into education.

4. Ability to work collaboratively across departments and communicate with physicians, nurses, coders, and revenue cycle staff.

5. Strong organizational and problem-solving skills.

6. Knowledge of Medicare/Medicaid regulations, payer policies, and the Two-Midnight Rule.

7. Strong understanding of denial management, CDI workflows, and HIM compliance.

8. Demonstrated ability to develop curriculum, lead training, and present complex concepts to diverse audiences (physicians, nurses, coders, revenue cycle staff).

9. Proficiency in Epic, 3M 360, ClinIntell, and revenue cycle analytics tools preferred. Excellent communication, facilitation, and change management skills.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

553 SYSTEM Utilization Review