Clinical Documentation Improvement Specialist - Ambulatory

1.0 FTE - Day Shifts

Starting Pay - $38.64-$48.29 (based on experience)

At Olmsted Medical Center, we value our employees and are committed to providing a comprehensive and competitive benefits package. To keep up with the evolving trends, Olmsted Medical Center offers the following for employees who are employed at a 0.5 FTE or higher.

• Medical Insurance
• Dental Insurance
• Vision Insurance
• Basic Life Insurance
• Tuition Reimbursement
• Employer Paid Short-Term Disability and Long-Term Disability
• Adoption Assistance Plan

Qualifications:

• Professional certification in Clinical Documentation (CCDS, CDEO or Professional Coding Certification (CRC, CPC, or CCS-P))
• Five years coding and CDI experience
• Demonstrated analytical and planning skills
• Strong interpersonal and communication skills
• Experience in developing and presenting educational programs
• Self-motivated and self-directed and able to work independently
• Strong critical thinking and reasoning while displaying the ability to draw accurate conclusions

Job Responsibilities:

• Medical Record Review: Facilitates appropriate clinical documentation to support Hierarchical Condition Categories, ICD-10-CM specificity, and medical necessity of ambulatory visits. Follows outpatient CDI processes for performing medical record reviews, identifying opportunities to improve provider documentation, and querying physicians as needed to ensure that appropriate documentation appears in the medical record. Consistently meets established productivity targets for record review.
• Competency: Demonstrates knowledge of documentation requirements and coding guidelines that pertain to outpatient diagnosis coding to accurately reflect the complexity and medical necessity of the visit. Improves the overall quality and completeness of clinical documentation by performing chart reviews on a regular basis to analyze documentation completeness and accuracy to support CPT, ICD10 and HCPCS selections made by clinicians.
• Orientation: Provides initial CDI and coding orientation to new physicians, advanced practice providers and other key healthcare providers relating to documentation and coding expectations. Educates on key components to selecting an appropriate level of service as well as additional billable services with the supporting documentation.
• Education: Routinely provides one-on-one education to physicians, advanced practice providers, and other key healthcare providers regarding the need for accurate, specific, and complete clinical documentation in the patient's medical record. Interacts regularly with physicians, in the outpatient setting, providing ongoing education regarding compliant documentation. Assists with analysis, trending, and presentation of audit/review findings, potential issues, and their root cause.
• Communication: Proactively solicits clarification from physicians to ensure key aspects of care have been appropriately recorded in the patient's medical record. Collaborates with clinic and coding staff as needed regarding interactions with providers related to documentation in order to resolve physician queries. Communicates information effectively by responding to questions, concerns, and requests promptly. Encourages communication by promoting open dialogue. Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps identify problems, offers solutions, and participates in their resolution.
• Works with insurance payers on HCC coding and gap closures.
• Professional Growth and Development: Demonstrates responsibility and accountability for personal development by participating in continuing education offerings. Maintains competence related to HCC documentation requirements, ICD-10-CM code assignment, and coding guidelines.
• Technology: Utilizes software systems to collect and ensure the effectiveness of the data. Maintains integrity of data collection by ensuring accurate data entry. Demonstrates competence in navigation of software. Utilizes software as a resource in ensuring accurate documentation.
• Age Specific Competency: Supports provision of age/developmentally appropriate patient care in accordance with age specific guidelines for the specific age groups served. Knowledge of physical, motor/sensory, mental, psychosocial, safety, and developmental factors in the Age-Specific Care Guidelines is reflected in reviews of patient medical records and interactions with the multidisciplinary team.