Professional/Ambulatory Clinical Documentation Improvement Specialist

Fisher-Titus Medical Center•Norwalk, OH

11h•Hybrid

About The Position

The Ambulatory/Professional Fee Clinical Documentation Specialist (CDS) serves as an advisor and expert resource to providers, supporting accurate and complete clinical documentation that reflects patient complexity, risk profiles, and appropriate Evaluation and Management (E/M) service levels. The role supports professional fee billing accuracy, appropriate reimbursement, and compliance with applicable regulatory and industry standards. The CDS performs comprehensive chart reviews to identify clinically relevant information and documentation opportunities. The work focuses on recapturing and identifying chronic conditions represented by Hierarchical Condition Categories (HCCs), which contribute to patients’ risk-adjusted profiles and Risk Adjustment Factor (RAF) scores, and evaluating documentation and medical decision making to ensure the level of service is appropriately reflected. The CDS conducts pre-visit and post-claim reviews and provides clear, actionable education and feedback to providers on clinical documentation, diagnosis coding, E/M level assignment, and billing practices. The role collaborates with Professional Fee CDI leadership, clinical documentation colleagues, coding teams, and other organizational partners to improve documentation practices and support compliant patient care and reimbursement. This is a hybrid position that sometimes requires working in person and offers flexibility to work from home. Fisher-Titus describes this role as full-time and offers a comprehensive benefits package.

Requirements

At least two years of professional fee coding, clinical documentation, risk adjustment, or related healthcare experience.
High school diploma or equivalent required.
Knowledge of professional fee coding, E/M guidelines, HCCs, risk adjustment, RAF methodology, and clinical documentation principles.
Extensive clinical knowledge and understanding of anatomy, physiology, pathophysiology, and disease processes.
Strong critical-thinking skills and ability to apply clinical knowledge to identify indicators supporting patient acuity and medical record clarification.
Excellent written, verbal, interpersonal, and presentation skills.
Strong project management, organizational, and time-management skills.
Ability to communicate effectively with providers and people at all levels of the organization.
Ability to work independently and manage multiple priorities in a time-sensitive environment.
Proficiency with Microsoft Office applications, including Excel, Word, and PowerPoint.
Ability to develop clear, relevant, and meaningful educational materials for providers and team members.
Strong problem-solving, analytical, investigative, and decision-making skills.
Ability to interpret performance and outcome data and use findings to prioritize provider education and review activities.
Commitment to compliant, accurate, objective, and non-leading clinical documentation practices.
Maintain confidentiality and comply with applicable privacy, security, safety, and regulatory requirements.
Support Fisher-Titus’s mission, vision, and CARES values and demonstrate its key service behaviors.

Nice To Haves

Registered Nurse (RN) or Licensed Practical Nurse (LPN) experience is preferred but not required.
Associate degree preferred.
CCS-P, CPC, CRC, or another relevant coding or clinical documentation credential is required or preferred depending on organizational requirements.
Epic experience preferred.

Responsibilities

Conduct pre-visit reviews to identify opportunities to recapture previously documented HCC conditions and potential new or suspect conditions supported by clinical indicators and the medical record.
Conduct post-claim reviews of E/M encounters for opportunities involving medical decision making, patient acuity, E/M level assignment, diagnosis capture, and HCC documentation.
Provide individualized and group education to providers based on chart review findings, data analytics, performance trends, and documentation or coding opportunities.
Collaborate with Professional Fee CDI leadership, CDI and coding teams, and organizational partners to support program objectives, coordinate initiatives, and foster teamwork.
Use performance, outcome, and other available data to identify high-priority providers, specialties, encounter types, workflow opportunities, and educational needs.
Support the development, implementation, and evaluation of Professional Fee CDI workflows, processes, education schedules, and program initiatives.
Identify opportunities to clarify the medical record in a compliant, non-leading manner consistent with coding, documentation, query, regulatory, and organizational guidelines.
Create and deliver specialty-specific education and ongoing feedback to providers and team members.
Communicate with providers, CDI team members, coding, compliance, and other stakeholders through consultations, meetings, specialty sessions, and other appropriate forums.
Maintain current knowledge of CMS requirements, official coding guidelines, HCC models, risk adjustment principles, E/M guidelines, clinical documentation requirements, and industry standards.
Maintain confidentiality under HIPAA and applicable privacy and security requirements; follow organizational policies and procedures; demonstrate professionalism and respect; and pursue ongoing professional development.
Attend required education, staff meetings, and monthly rounding; complete department-specific training and comply with safety, security, and regulatory requirements.
Support patient rights, privacy, dignity, safety, quality assurance, regulatory compliance, and a work environment free from harassment and discrimination.
Demonstrate the organization’s service behaviors, including compassionate communication, service etiquette, commitment to safety, and continuous improvement of care and processes.