Reviews clinical documentation and coding during ambulatory encounters and possibly prospectively or retrospectively, to determine opportunities to improve physician documentation and communicates identified opportunities to the physician. Conducts timely follow-up reviews to ensure appropriate clinical documentation is recorded in patient's chart and appropriate ICD-10 codes are attached to the visit.
Performs concurrent medical record reviews facilitating improvement in the quality, completeness and accuracy of medical record documentation to ensure coding compliance, accurate reporting, appropriate risk scoring, and improved patient outcomes. Performs prospective and/or retrospective reviews as assigned.
Maintains knowledge of coding and billing rules and regulations to ensure that the documentation in the medical record supports appropriate reimbursement.
Participates in assuring ambulatory and payor coding/documentation compliance with Federal and State regulatory bodies.
Educates members of the patient care team, including medical staff, on documentation guidelines on an on-going basis.
Facilitates appropriate modifications to clinical documentation to accurately reflect patient severity of illness and risk through extensive interaction with physicians, case management staff, nursing staff, other patient caregivers, and coding staff. With Director and Supervisor’s guidance, collaborates with coding staff to develop standard coding guidelines, policies and procedures.
Submits verbal, electronic or written queries as appropriate, to clinicians to ensure documentation of complete and accurate records to allow coding assignments post encounter that will accurately reflect the severity and risk of mortality of the patient population.
Ensures the accuracy and completeness of clinical information used for measuring and reporting physician, hospital and regulatory outcomes. Reviews data and trends to identify additional areas of opportunity. Provides input to core measure and other quality data initiatives regarding areas for investigation and education.
Delivers provider specific metrics ad coach providers on Gap closing opportunities as needed
What You Will Need:
Education and Experience Required:
Clinical experience per licensure/certification requirements listed below
At least two (2) years of experience as a concurrent or retrospective documentation specialist depending on degree
Licensure, Certification, OR Registration Required:
CDIP, CCDS or CPC (Clinical Documentation Improvement Practitioner/Certified Clinical Documentation Specialist/Certified Professional Coder) AND EITHER
Three (3) years of experience as a concurrent OR retrospective documentation specialist.
Knowledge and Skills Required:
High level of interpersonal and communication skills necessary to establish rapport with physicians and other healthcare providers.
Minimum MS Office (Word, Outlook, Excel and PowerPoint) knowledge
Strong Ambulatory Background (Preferred)
Experience with Medicare risk adjustment, Hierarchical Condition Categories, coding, billing, auditing and various healthcare payers (Preferred)
Experience with Care Gaps (Preferred)
The Specialist Ambulatory CDI Senior demonstrates strong clinical knowledge and understanding of coding/Hierarchical Condition Categories (HCC)/Risk Adjustment Factor (RAF) requirements and Clinical Care Gaps to improve overall quality and completeness of clinical documentation in the patient medical record on a concurrent, and potentially a prospective and retrospective basis, using a multi-disciplinary team process. The Specialist Ambulatory CDI Senior works collaboratively with physicians, other healthcare professionals and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate clinical severity, outcomes and quality is captured for the level of service rendered to all patients, as well as ensuring compliant reimbursement and risk adjustment factors scores. This position is responsible for understanding the clinical Care Gaps for different populations, using physicians’ education and multi-disciplinary team approach to help closing them.
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