Ambulatory Certified Coding Specialist / Clinical Documentation Specialist

Trinity Health•Newtown Square, PA

13d•Remote

About The Position

Trinity Health Mid-Atlantic, is looking for a CIN Ambulatory Clinical Documentation Specialist to join our team! Employment Type: Full Time Schedule: This is a full-time remote position. Day shift, Monday - Friday. Specific schedule to be further discussed by department based on needs. Job Description: Utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator, and consultant. Facilitates the overall quality, completeness, accuracy, and integrity of medical record documentation through extensive record review. Through interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment and burden of illness, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team. Demonstrates understanding of appropriate clinical documentation to ensure the severity of illness, risk of mortality, quality indicators are accurately reflected in the health record. Assists in overall quality, timeliness, and completeness of the health record to ensure appropriate data, provider communication and quality outcomes and identifies incomplete or inconsistent documentation in the record which impacts HCC or other risk score coding. Conducts pre and post encounter medical record review coding and documentation for accuracy and completeness. Identifies opportunities for increased coding accuracy and communicates with provider prior to claim submission to ensure accurate burden of illness identification. Conducts medical record audit of selected patient health records to address legibility, clarity, completeness, consistency, and accuracy of clinical documentation to support burden of illness. Provides training to health care professionals in ICD-10-CM, CPT, and HCPCS Coding Guidelines, modifier guidelines, documentation guidelines, medical terminology, and disease processes.

Requirements

Must possess a Degree in Nursing (BSN, AS or Diploma), or an Advanced degree in Medical Field
If RN, Current Registered Nurse License
Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), or Certified Documentation Improvement Professional (CDIP) (or obtained within 6months of hire)
Previous coding experience in the outpatient setting required.
Minimum of one year Risk Adjustment Validation experience required.

Responsibilities

Direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator, and consultant.
Facilitates the overall quality, completeness, accuracy, and integrity of medical record documentation through extensive record review.
Achieves appropriate clinical documentation to support code assignment and burden of illness, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients.
Participates in the development and delivery of education for providers and members of the healthcare team.
Demonstrates understanding of appropriate clinical documentation to ensure the severity of illness, risk of mortality, quality indicators are accurately reflected in the health record.
Assists in overall quality, timeliness, and completeness of the health record to ensure appropriate data, provider communication and quality outcomes and identifies incomplete or inconsistent documentation in the record which impacts HCC or other risk score coding.
Conducts pre and post encounter medical record review coding and documentation for accuracy and completeness.
Identifies opportunities for increased coding accuracy and communicates with provider prior to claim submission to ensure accurate burden of illness identification.
Conducts medical record audit of selected patient health records to address legibility, clarity, completeness, consistency, and accuracy of clinical documentation to support burden of illness.
Provides training to health care professionals in ICD-10-CM, CPT, and HCPCS Coding Guidelines, modifier guidelines, documentation guidelines, medical terminology, and disease processes.