CLINICAL DOCUMENTATION SPECIALIST II
About The Position
The Clinical Documentation Specialist II improves the quality and completeness of provider-based clinical documentation in the medical record by working directly with providers. The role helps ensure documentation accurately reflects patients’ severity of illness, risk of mortality, complexity of care, and hierarchical condition categories. The specialist reviews medical records extensively, applies clinical judgment and artificial intelligence, and collaborates with providers to clarify documentation so it accurately and completely reflects patients’ medical conditions. The role identifies opportunities for documentation improvement, conducts independent research to ensure compliance when developing provider queries, and applies evolving AHIMA and ACDIS standards while maintaining current knowledge of coding updates released in April and October. The position collaborates with physicians, mid-level providers, nursing staff, and other patient caregivers, and develops and delivers education through Zoom meetings, telephone discussions, and email.
Requirements
- Associate’s degree in Nursing, Health Information Management, or another healthcare-related field.
- At least four years of acute care clinical documentation experience.
- Experience applying Medicare, Medicaid, and commercial payer regulations, charging and coding guidelines, and healthcare regulations.
- Knowledge of ICD-10-CM and ICD-10-PCS coding.
- Experience performing independent queries.
- Proven ability to combine clinical knowledge and coding skills.
- Ability to identify documentation improvement opportunities and collaborate with providers to address them.
- Proficiency with MS Office, Optum 360 eCAC, and Cerner EHR.
- Organized, analytical, and strong interpersonal and writing skills.
- Dependable and self-directed, with critical thinking, problem-solving, and deductive reasoning skills.
- Knowledge of the healthcare regulatory environment.
- Understanding of and support for clinical documentation management strategies.
- Flexibility to accommodate clinician schedules.
- Knowledge of Case Mix Index and how it is influenced.
- Must hold one of the following certifications: CCDS from ACDIS, CDIP from AHIMA, or CDEI from AAPC; an active RN satisfies the certification requirement in lieu of a listed certification.
Nice To Haves
- Two years of oncology experience.
- Vizient experience.
Responsibilities
- Review medical records and assess clinical documentation using clinical judgment and artificial intelligence.
- Work with treating providers to clarify documentation and ensure it accurately reflects patients’ medical conditions, severity of illness, risk of mortality, complexity of care, and hierarchical condition categories.
- Identify opportunities for documentation improvement and hold collaborative discussions with providers to address them.
- Conduct independent research to ensure compliance when developing provider queries.
- Interpret and apply evolving standards from AHIMA and ACDIS, and maintain current knowledge of coding changes and updates.
- Collaborate with physicians, mid-level providers, nursing staff, and other patient caregivers.
- Develop and deliver education through Zoom meetings, telephone discussions, and email.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
