Clinical Documentation Manager

Zotec Partners • , (Multiple States)

2d • Remote

About The Position

At Zotec Partners, we are seeking a Clinical Documentation Manager to join our team. This is a remote position. As a Clinical Documentation Manager, you will perform concurrent and retrospective review of the medical record, provider education, and educate clinicians to ensure the documentation of all clinical conditions and procedures within the medical record accurately reflect the condition(s) and treatment(s) of the patient. You will also respond to coding queries and contribute to the development and training of coding staff. Primary duties are to ensure that documentation reflects the appropriate CPT and ICD-10 assignment in accordance with Medicare or other payor guidelines and provide constructive, educational feedback to the providers and/or coders.

Requirements

• Minimum of 5 years coder training and/or chart auditing experience for coding of the professional (physician) component required and coding experience of the facility component (hospital) also preferred
• Experience as clinical nurse or a Clinical Documentation Integrity Specialist
• Versed in medical terminology and clinical procedures
• Understanding of the workflow in the Emergency Department
• Awareness of payor-specific coding/reimbursement policies
• Coding certification required
• Associate or bachelor’s degree in healthcare-related field
• Extensive knowledge of CPT, ICD-10-CM and HCPCS coding guidelines as well as MIPS Quality Reporting
• Excel and Word experience required
• Exceptional oral and written communication skills
• Strong organizational and problem-solving skills
• Flexible mentality: willing and capable of performing varied tasks
• Ability to work in a team driven environment

Responsibilities

• Communicate and educate providers concerning accurate clinical documentation
• Collaborate with healthcare professionals to ensure the severity of illness and level of care provided are accurately reflected in the medical record and to resolve physician queries and documentation issues
• Educate Emergency Medicine providers regarding clinical documentation improvement, documentation guidelines and the need for accurate and complete documentation in the health record
• Partner with coding professionals to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation to determine the appropriate CPT assignment.
• Review/audit of medical records to determine correct coding and corrective action plans, including education via email, phone call or Zoom
• Provide ongoing training including coding updates and refresher topics
• Address client issues/questions regarding coding
• Assist in new client start-ups from a coding documentation perspective
• Perform special audits as requested
• Work as an involved team member with the goal of achieving excellent coding accuracy
• Support other offices/departments as necessary on the above noted functions
• Actively participate in coding committees, conference calls and meetings
• Other duties as assigned

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree