Documentation Integrity & Coding Compliance Specialist – Full-Time (80 hours per pay period)

Bronson Healthcare

1d • Hybrid

About The Position

The Documentation Integrity & Coding Compliance Specialist utilizes advanced coding knowledge, clinical documentation expertise, risk adjustment methodology, CMS-HCC knowledge, and regulatory compliance standards to direct efforts toward the improvement of clinical documentation through the role of educator, consultant, and subject matter expert. The specialist facilitates improvement in the overall quality, completeness, specificity, and accuracy of medical record documentation through extensive record review, audit analysis, provider education, and collaboration with interdisciplinary teams.

The focus of this role is to perform primary and ongoing assessment of documentation in the medical record to identify gaps, inconsistencies, unsupported diagnoses, missed risk adjustment opportunities, and opportunities for improved coding accuracy and compliance. When finding deficits, the specialist coaches physicians and advanced practice providers regarding documentation improvements that better reflect the patient’s true patient complexity, chronic condition burden, risk adjustment profile, services rendered, and value-based care impact. This improved documentation supports accurate coding, reimbursement optimization, RAF performance, audit readiness, and organizational compliance.

The Documentation Integrity & Coding Compliance Specialist gathers and analyzes data, identifies trends, develops improvement plans, and creates tools or education resources to address identified documentation and coding challenges. This may range from development of audit tools and provider feedback materials to one-on-one coaching with a provider or coder requiring additional support.

Clinical denials, payer audits, risk adjustment validation, and regulatory reviews continue to be a frequent focus of insurance and regulatory agencies. The specialist supports these processes through record review, documentation and coding analysis, denial prevention, audit defense preparation, and assistance with written responses or appeal support as appropriate.

Employees in this role must demonstrate competencies specific to documentation integrity, coding compliance, risk adjustment, provider education, and the populations served.

Requirements

• Bachelor’s degree required
• Experience in clinical documentation integrity, coding compliance, risk adjustment, provider education, revenue cycle, medical record auditing, or related healthcare operations required.
• Strong knowledge of ICD-10-CM, CPT, HCPCS, CMS-HCC methodology, coding guidelines, documentation requirements, reimbursement methodologies, and regulatory compliance standards required.
• RN may be required for role in certain departments.
• Required certifications: CRC – Certified Risk Adjustment Coder and CPC – Certified Professional Coder.
• Must possess exceptional communication and interpersonal skills
• Must be self-directed and flexible
• Must demonstrate positive relationships with physicians, advanced practice providers, coding staff, CDI staff, quality teams, revenue cycle teams, and operational leaders
• Must possess leadership abilities and promote collaboration
• Must be willing to accept high level of responsibility and accountability
• Must possess strong analytical skills, advanced problem solving ability, and is able to role model and teach others in a non-threatening supportive manner
• Must be knowledgeable of Bronson / Community systems related to assigned service line or area of responsibility
• Must be able to attend to detail without losing sight of overall goals, compliance priorities, or operational impact
• Must be able to function effectively in a fluid, dynamic, and rapidly changing environment
• External contacts include: insurance companies, Medicare and Medicaid, auditors, consultants, regulatory agencies, and payer or compliance-related entities
• Must be able to discern issues and maintain composure with physicians and staff.
• Work which produces very high levels of mental/visual fatigue, e.g. computer-based medical record review between 70 and 90 percent of the time, and work involving extensive review, analysis, and interpretation of clinical, coding, and regulatory information for sustained periods of time.

Nice To Haves

• Master’s degree preferred.
• CDEO – Certified Documentation Expert Outpatient strongly preferred at hire and required within twelve months of employment.
• CVBA – Certified Value-Based Associate recommended/preferred but not required.
• RN license is not required for this position.
• Prefer experience with risk adjustment strategy, RAF optimization, CMS-HCC documentation, audit defense preparation, coding quality audits, and value-based care models

Responsibilities

• Responsible for clinical documentation analysis, documentation completeness, coding accuracy, coding compliance, and risk adjustment documentation integrity.
• Facilitates modifications and clarification to clinical documentation in order to support accurate hospital, physician, professional, and value-based billing and reporting.
• In order to present an accurate hospital, physician, and provider profile, all diagnoses, services, and applicable procedures must be documented in the medical record and must properly reflect the level of services being provided. Will work with individual physicians and advanced practice providers to achieve this goal.
• Acting as an expert coding, documentation, compliance, and risk adjustment resource for coding, CDI, quality, revenue cycle, and operational teams.
• Timely communication with assigned service line physicians, advanced practice providers, coding staff, CDI staff, and multidisciplinary teams.
• Performs initial case reviews and appropriate follow-up reviews based on judgment of documentation, coding, risk adjustment, compliance risk, documented clinical information , and audit findings.
• Performs accurate and timely concurrent and retrospective reviews of medical records to include evaluation of ICD-10-CM, CPT, HCPCS, CMS-HCC capture, documentation consistency , documentation specificity, coding accuracy, and regulatory compliance.
• Documents findings in applicable audit, CDI, coding, or reporting tools and verifies key documentation and coding information, as appropriate.
• Improves the overall quality and completeness of clinical documentation by interpreting clinical information in the medical record, evaluating diagnoses, medications, treatment plans, test results, visit documentation, and applicable payer and regulatory requirements.
• Recognizes opportunities for documentation improvement. Works collaboratively with medical staff, advanced practice providers, coding staff, CDI staff, revenue cycle staff, and quality teams to improve the quality of chart documentation to accurately reflect patient complexity, chronic condition burden, risk adjustment accuracy, HCC capture, services provided, and compliance requirements.
• Initiates communication with physicians and advanced practice providers, through verbal or electronic means, in order to obtain or offer more specific documentation of diagnoses, co-morbidities, HCC conditions, clinical indicators, and services rendered.
• Solicits clarification of existing documentation in the medical record that supports patient complexity, chronic condition burden, risk adjustment accuracy, coding accuracy, and compliance.
• Collaborates with coding staff on meeting coding guidelines, interpreting tracking information, developing profiling and reporting by service in data review, and with physician education related to documentation requirements.
• Develops and presents pertinent audit findings, trends, recommendations, education, and performance information to appropriate administrative, clinical, operational, compliance, provider, and committee stakeholders.
• Able to articulate and demonstrate commitment both to program goals and to the vision, values, and mission of Bronson

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level