Ambulatory RN Clinical Documentation Integrity Specialist
About The Position
The Ambulatory Clinical Documentation Integrity Specialist (CDS) is a clinical position using clinical/nursing knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic health record (EHR) using a multidisciplinary team process. Works collaboratively with ambulatory physicians, advance practice providers and HCC coding specialists to ensure the clinical information within the EHR is accurate, complete, and compliant. This includes accurate documentation to support the capture of Hierarchical Condition Categories (HCC), ICD-10-CM specificity and medical necessity of ambulatory visits. Compliantly queries the provider as needed in their prospective chart reviews to ensure specification and clarification of documentation is captured at the time of the patient’s visit. In addition, the CDS educates members of the patient care team both formally and informally regarding documentation guidelines, coding requirements and service specific requirements.
Requirements
- Associate degree in nursing (ADN) required
- Minimum 3 years clinical experience within an inpatient or ambulatory setting
Nice To Haves
- CRC or CCDS, preferred. CRC will be required to obtain a professional coding certification within six months of hire
Responsibilities
- Partners with operational and physician advisors to identify, develop and implement successful communication and education, to engage providers and improve outcomes, processes and support HCC capture of ambulatory visits
- Performs daily medical record reviews and data collection activities to identify documentation issues, quality issues and opportunities for improvement
- Ensures level of service and acuity of care is accurately reflected in quality outcomes
- Demonstrates knowledge of documentation requirements and coding guidelines that pertain to ambulatory diagnosis coding to accurately reflect the complexity and medical necessity of the visit.
- Monitors, assists, and tracks the progress of the program through analysis, trending and presentation of audit/review findings, potential issues, and their root cause.
- Serves as a resource to physicians and administration regarding issues related to compliant documentation.
- Educates Physicians and Staff regarding the need for accurate, specific, and complete clinical documentation in the patient’s medical record.
- Collaborates with Physicians, Advanced Practice Providers, Ambulatory CDI Staff, and HIM/Ambulatory Coders as well as works directly with individuals and departments where documentation improvement opportunities exist.
- Demonstrates responsibility and accountability for personal development by participating in continuing education offerings and maintaining credentials required for role.
- Utilizes software systems to collect and ensure the effectiveness of the data.
- Maintains the integrity of data collection by ensuring accurate data entry and demonstrates competence in navigation of software.
- Applies knowledge of professional nursing standards, best practices, and interdisciplinary collaboration to advance problem analysis and resolution and creative process redesign.
- Assists the coding team leads with onboarding new coding specialists to the role as needed.
- Excellent communication skills (verbal and written) to enable effective outcomes with diverse complex clinical care teams
- Consistently maintains a minimum 95% accuracy on documentation quality audits
- Meet minimum productivity requirements as outlined by the project terms
Benefits
- Career Pathways to Promote Professional Growth and Development
- Various Medical, Dental, Pet and Vision options
- Tuition Reimbursement
- Free Parking
- Wellness Program
- Savings Plan
- Health Savings Account Options
- Retirement Options with Company Match
- Paid Time Off and Holiday Pay
- Community Involvement Opportunities
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
