Clinical Documentation Improvement Specialist

<p>The Clinical Documentation Improvement Specialist is responsible for improving the overall quality, timeliness and completeness of clinical documentation.&nbsp; 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.</p>
<p>&nbsp;</p>
<p><strong><u>Essential Duties and Responsibilities: </u></strong></p>
<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. &nbsp;&nbsp;</li>
<li>Other duties as assigned.</li>
</ul>
<p><strong>&nbsp;</strong></p>
<p><strong><u>Required Knowledge, Skills and Abilities:</u></strong></p>
<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>
<p>&nbsp;</p>
<p><strong><u>Education/Experience/Licensure:</u></strong></p>
<p><strong>Education:&nbsp;</strong>Bachelor’s or Associate’s degree in nursing or health information management or related healthcare field preferred.</p>
<p><strong>Experience:</strong>&nbsp; Three (3) years of clinical experience in an outpatient office setting.&nbsp; One (1) year Case Management or Utilization Management experience preferred.</p>
<p><strong>Certification/Licensure:&nbsp;</strong>Licensed Registered Nurse, BSN, or LPN.&nbsp; Certified Clinical Documentation Specialist, RHIA, RHIT or Coding Certified from AHIMA or AAPC required.</p>