Clinical Documentation Improvement Specialist

The Clinical Documentation Improvement Specialist is responsible for improving the overall quality, timeliness and completeness of clinical documentation.  This position will facilitate modifications to clinical documentation through extensive interaction with providers, clinical staff, and billing/coding staff to ensure appropriate reimbursement is received for the level of service rendered to all patients.
 
Essential Duties and Responsibilities: 
<ul>
<li>Collaborates extensively with providers, clinical staff and billing/coding staff to improve quality and completeness of documentation of care provided and coded.</li>
<li>Queries providers to clarify ambiguous, conflicting, or incomplete documentation.</li>
<li>Provides direction for concurrent modification to clinical documentation to ensure appropriate coding for reimbursement for clinical severity and services provided to patients.</li>
<li>Provides ongoing training and education to all members of the patient care team.</li>
<li>Reviews clinical documentation to ensure medical necessity is met per payer reimbursement policies.</li>
<li>Facilitates modification to clinical documentation to ensure that the medical record presents an accurate patient clinical picture and intent of the provider.</li>
<li>Conducts concurrent and retrospective reviews of medical records to increase the accuracy, clarity and specificity of provider documentation.</li>
<li>Collaborates with Lead Physicians to assist in identifying coding and documentation outliers within their provider groups and provides guidance and education as needed.   </li>
<li>Other duties as assigned.</li>
</ul>
 
Required Knowledge, Skills and Abilities:
<ul>
<li>Knowledge of electronic medical records, health information systems and healthcare applications and their effects on coding practices.</li>
<li>Knowledge of ICD-10-CM and CPT coding guidelines for professional services.</li>
<li>Experience with concurrent reviews for new providers.</li>
<li>Knowledge of medical terminology, classifications systems and vocabularies.</li>
<li>Knowledge of privacy and security regulations, confidentiality, and access and release of information practices.</li>
<li>Experience in assisting and identifying learning needs as well as providing education and training designed to support a learning organization.</li>
<li>Excellent oral, written and interpersonal communication skills.</li>
<li>Ability to organize and set priorities to ensure objectives are met in a timely manner.</li>
<li>Ability to adapt to change and handle challenges proactively and with pose.</li>
<li>Ability to effectively collaborate with providers and managerial staff at all levels.</li>
<li>Ability to travel to clinics to work one on one with providers and/or clinical staff is required.</li>
</ul>
 
Education/Experience/Licensure:
Education: Bachelor’s or Associate’s degree in nursing or health information management or related healthcare field preferred.
Experience:  Three (3) years of clinical experience in an outpatient office setting.  One (1) year Case Management or Utilization Management experience preferred.
Certification/Licensure: Licensed Registered Nurse, BSN, or LPN.  Certified Clinical Documentation Specialist, RHIA, RHIT or Coding Certified from AHIMA or AAPC required.

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