Clinical Documentation Specialist I - Remote
About The Position
The Clinical Documentation Specialist supports efforts to improve the quality, completeness, and accuracy of clinical documentation and coding in outpatient physician practices. The role works with physicians, Health Information Management, and the Mount Sinai Health Partners team to review and code ambulatory medical records, identify opportunities to improve coding, educate physicians, and serve as a liaison among stakeholders. The specialist reviews outpatient records and diagnoses, performs coding and clinical validation audits, analyzes documentation alerts, and seeks clarification from physicians when needed. The role has a particular focus on primary care and Hierarchical Condition Categories (HCC) risk-adjustment coding. It also contributes to performance reporting, clinician education and coaching, and monitoring compliance with payer regulations and coding changes.
Requirements
- High school diploma or GED.
- At least 3 years of coding experience.
- One or more of the following credentials 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.
- 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 to present clear and concise results.
Nice To Haves
- Associate degree or higher.
- At least 1 year of HCC Risk Adjustment experience.
- Clinical background in a healthcare setting.
- Familiarity with CMS HCC Risk Adjustment coding and data validation requirements.
- Familiarity with APC coding.
Responsibilities
- Improve the quality, completeness, and accuracy of medical record documentation and coding.
- Review charts to assess patient clinical status, treatment plans, and medical history, identifying documentation gaps in outpatient encounters, particularly primary care visits.
- Perform on-site or electronic coding and clinical validation audits and interpret medical documentation to ensure all relevant coding is captured, with a focus on HCC coding.
- Use available information technology data, such as 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 ensure they accurately reflect patients’ clinical status and care delivered.
- Request clarification from physicians to ensure key aspects of care are appropriately documented in patient 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 governmental 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
