Clinical Documentation Specialist I - Remote
About The Position
MSHP seeks a Clinical Documentation Specialist to improve the quality and completeness of clinical documentation and coding in outpatient physician practices. The specialist works closely with physicians, Health Information Management, and the Mount Sinai Health Partners team to review and code ambulatory medical records, identify coding improvement opportunities, educate physicians, and serve as a liaison among these groups. The work focuses particularly on primary care visits and Hierarchical Condition Categories (HCC) risk-adjustment coding. The role includes reviewing outpatient documentation and diagnoses, conducting coding and clinical validation audits, using available information technology and billing data to identify coding opportunities, and communicating findings to physicians and practice staff. The specialist also supports compliant documentation and accurate coding through education, coaching, reporting, and monitoring of coding changes and payer requirements.
Requirements
- High school diploma or GED required; an associate degree or higher is preferred.
- At least 3 years of coding experience.
- A credential in one or more of the following is required: Certified Coding Specialist (CCS), Certified Risk Adjustment Coder (CRC), or Certified Professional Coder (CPC).
- Demonstrated experience with front-end process improvement initiatives.
- Thorough knowledge of ICD-10, CPT, and HCPCS.
- Familiarity with and understanding of CMS HCC risk-adjustment coding and data validation requirements.
- Familiarity with APC coding.
- Experience with Microsoft Excel.
- Strong communication and mentoring skills, including the ability to communicate clearly and effectively with individuals at all organizational levels.
- Strong time management and organizational skills.
- High degree of accuracy, efficiency, and dependability.
- Excellent written and oral communication skills for presenting clear and concise results.
Nice To Haves
- At least 1 year of HCC risk-adjustment experience.
- Clinical background in a healthcare setting.
- Associate degree or higher.
Responsibilities
- Improve the overall quality, completeness, and accuracy of medical record documentation and coding.
- Review charts to assess patients’ clinical status, treatment plans, and medical histories, identifying documentation gaps related to outpatient encounters, particularly primary care visits.
- Perform on-site or electronic coding and clinical validation audits, interpreting medical documentation to ensure all relevant coding is captured, with a focus on HCC coding.
- Use available information technology, including billing data, to identify opportunities to improve the comprehensiveness and specificity of outpatient coding.
- Coordinate chart reviews with physician office staff and distribute related correspondence.
- Analyze returned CDQI alerts for accuracy and completeness.
- Review outpatient visit diagnoses and service levels before claim submission to verify that they accurately reflect patients’ clinical status and the care delivered.
- Solicit clarification from physicians to ensure key aspects of care are documented in patients’ charts.
- Participate in data acquisition, prepare performance reports, and communicate results to physicians, practice managers, and the CDQI leadership team.
- Provide ongoing education to physicians, particularly primary care providers, on compliant documentation and accurate coding, and serve as a clinical liaison to the coding department.
- Identify training needs, prepare summary reports, and coach clinicians and other staff to improve documentation of members’ health status.
- Monitor coding changes from government agencies and other payers and educate practices on coding and compliance issues.
- Monitor activities to ensure clinical documentation complies with state and federal payer regulations.
- Perform other related duties.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
