Clinical Documentation Specialist I

Mount Sinai Health System • New York, NY

3d

About The Position

MSHP seeks a Clinical Documentation Specialist to support the quality and completeness of clinical documentation and coding in outpatient physician practices. The specialist 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 the parties. The role focuses particularly on primary care visits and Hierarchical Condition Categories (HCC) coding, which CMS and other payers use to assess illness complexity and estimate future healthcare utilization.

Requirements

• High school diploma or GED required; an associate degree or higher is preferred.
• At least 3 years of coding experience.
• A credential in at least one 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 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 people 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

• At least 1 year of HCC Risk Adjustment experience.
• Clinical background in a healthcare setting.
• Associate degree or higher.

Responsibilities

• Improve the quality, completeness, and accuracy of medical record documentation and coding.
• Review charts to assess patients’ clinical status, treatment plans, and medical histories, and identify documentation gaps related to outpatient encounters, particularly primary care visits.
• Conduct on-site or electronic coding and clinical validation audits and interpret medical documentation to ensure relevant coding is captured.
• 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 reflect patients’ clinical status and the care delivered.
• Seek clarification from physicians to ensure key aspects of care are documented in patients’ charts.
• Participate in data acquisition, develop 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 quality and accurately reflect 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED