Clinical Documentation Specialist
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Job Description
Clinical Documentation Specialist ensuring accurate clinical documentation and provider education. Focused on improving risk profiles and billing processes through expert analysis.
Responsibilities:
- Serve as an advisor and expert resource for providers to improve the accuracy of clinical documentation to support patient complexity, risk profiles and appropriate E/M levels
- Assist providers in identifying clinically relevant information and capturing the clinical documentation needed to accurately reflect patient acuity
- Focus on the recapture and identification of chronic conditions reflected in Hierarchical Condition Categories (HCCs)
- Complete pre-visit and post-claim reviews as well as providing clear communication and education to providers on their documentation, coding and billing practices
- Coordinate with colleagues from the CDI Program or other members of the organization regarding education and training geared towards improving clinical documentation
Requirements:
- High School Equivalent / GED (Required)
- Associate's Degree (Preferred)
- 3+ years Coding and/or clinical documentation integrity (Required)
- Extensive clinical knowledge and understanding of pathophysiology (Required proficiency)
- Strong critical thinking skills and utilization of clinical knowledge to identify potential clinical indicators supporting patient acuity and clarifications of the medical record (Required proficiency)
- Excellent written and verbal communication skills (Required proficiency)
- Strong project management skills (Required proficiency)
- Strong interpersonal skills, with demonstrated success at communicating effectively with all levels of the organization (Required proficiency)
- Ability to work independently in a time-oriented environment (Required proficiency)
- Demonstrates skilled ability and comfort with electronic medical records (EPIC preferred) (Required proficiency)
- Proficient with personal computer applications (Excel, Word, and Power Point) (Required proficiency)
- Ability to build education material that is meaningful for providers and team members (Required proficiency)
- Strong problem solving and investigative skills (Required proficiency)
Benefits:
- Maintains strict confidentiality of all patients, employee and physician information according to HIPAA guidelines
- Shares in organization’s vision, demonstrates its values, supports its philosophy and is sensitive to its mission.
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