Clinical Documentation Specialist
About The Position
The Clinical Documentation Specialist at Quincy Medical Group advances Value-Based Care initiatives by partnering with providers to improve clinical documentation, diagnosis capture, and coding accuracy. The role serves as a resource and educator, helping ensure medical records accurately reflect the complexity of patient care while supporting regulatory compliance, quality outcomes, and organizational performance. The specialist works collaboratively with providers, clinical leaders, coding professionals, and operational teams to identify documentation improvement opportunities, provide individualized education, and implement best practices. The position is full-time, Monday through Friday during daytime hours, with schedule flexibility as needed for provider education sessions and organizational initiatives. It supports providers across multiple specialties in a collaborative environment.
Requirements
- Strong analytical, critical thinking, and problem-solving skills.
- Excellent presentation, communication, and relationship-building abilities.
- Ability to educate and influence providers through collaborative coaching and feedback.
- Strong organizational skills with the ability to manage multiple priorities independently.
- Proficiency with electronic medical records and Microsoft Office applications.
Nice To Haves
- Bachelor's degree in nursing, health information management, healthcare administration, or a related field.
- Current RN license or comparable clinical background.
- Certified Professional Coder (CPC), Certified Risk Adjustment Coder (CRC), or ability to obtain certification within six months of hire.
- Minimum of two years of experience in clinical documentation improvement, risk adjustment, coding, quality, population health, or a related healthcare field.
- Working knowledge of ICD-10 coding, CMS documentation requirements, and risk adjustment principles.
Responsibilities
- Partner with providers to improve clinical documentation, diagnosis capture, and coding accuracy.
- Provide education and training on documentation best practices, risk adjustment principles, and applicable coding guidelines.
- Review medical record documentation to identify opportunities for improved specificity, completeness, and accurate diagnosis capture.
- Analyze documentation trends, audit findings, and performance metrics to develop targeted provider education.
- Serve as a subject matter expert on documentation integrity, regulatory requirements, and clinical documentation improvement initiatives.
- Collaborate with coding, quality, operations, and clinical leadership teams to support organizational goals.
- Develop educational resources, job aids, and reference materials that support provider success.
- Monitor documentation performance and assist with developing action plans to improve documentation quality and compliance.
- Maintain current knowledge of CMS guidance, ICD-10, HCC risk adjustment, and industry best practices.
- Support ongoing quality improvement initiatives and process enhancement efforts.
- Build collaborative relationships with providers, clinic leadership, and interdisciplinary teams.
- Perform other duties as assigned to support Value-Based Care initiatives.
Benefits
- Comprehensive medical, dental, and vision benefits that include healthcare navigation assistance.
- Access to a mental health benefit at no cost.
- Employer provided life and disability insurance.
- $5,250 tuition reimbursement per year.
- Immediate 401(k) match.
- Flexible time off.
- 40 hours paid volunteer time off.
- Up to 12 weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members once eligibility requirements are met.
- Additional compensation may be available through bonuses and other incentives.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
