Specialist CDI - Outpatient/Risk Adjustment

Cano Health•Miami, FL

56d•Hybrid

About The Position

Full-Time role of Clinical Documentation Improvement Specialist (CDIS) plays a critical role in ensuring accurate and complete clinical documentation that reflects the severity of patient conditions and supports the accurate coding of diagnoses for all our patients. This position focuses on optimizing documentation to reflect the true clinical picture, improving the quality of risk adjustment data, and ensuring compliance with CMS (Centers for Medicare & Medicaid Services) guidelines. The CDI Specialist works closely with physicians, clinical and administrative staff, and the coding team to educate and guide them in capturing precise and comprehensive diagnoses and patient information that will support accurate risk adjustment coding (HCC - Hierarchical Condition Categories). This role also involves reviewing medical records, identifying gaps in documentation, and facilitating clarification to ensure that the documentation supports the correct code assignment, ultimately driving accurate reimbursement and improved patient care management.

Requirements

Associate's or Bachelor's degree in healthcare, nursing, or a related field.
Five (5) or more years as a coding and billing specialist (ICD-10, CPT, and HCPCS).
Advanced analytical and data manipulation skills
AAPC certifications (CRC, CDEO, CPMA, etc.).
New hires must be CPC Certified from AAPC or AHIMA equivalent
Minimum three (2) years as Clinical Documentation Improvement Specialists or Similar roles, inclusive but not limited to any of Coding and Billing Auditing (ICD-10, CPT, and HCPCS) or the equivalent of 5 or more years as Risk Adjustment Coding and Billing Specialist
Computer Level: Proficient (including MS-Outlook, Word, Excel, and Power Point).
Languages: Bi-lingual (English/Spanish).
Advance coding background.
Advance Medical terminology, Anatomy, Pharmacology and Disease management Knowledge.
Advance written and verbal communication skills.
Strong time management skills.
Organized, able to plan and complete work in targeted timeframe.
Demonstrated critical thinking, decision-making skills relative to clinical documentation (and coding auditing functions).
Strong organization, training and process management skills.
Strong collaboration and relationship building skills.
High attention to detail.
Ability to learn new tasks and concepts.
Builds Trust: Consistently models and inspires high levels of integrity, lives up to commitments and takes responsibility for the impact of one's actions.
Pursues Excellence: Seeks out learning, strives to develop and expand personally, and continuously helps others upgrade their capability to contribute to the managed care plan.
Executers for Results: Effectively leverages resources to create exceptional outcomes, embraces changes and constructively resolves barriers and constraints.
Collaborates: Engages others by gathering multiple views and being open to diverse perspectives, focusing on a shared purpose that places emphasis on the success of the medical centers and insurance companies.

Nice To Haves

Attention to detail and accuracy in clinical documentation review.
Strong understanding of Medicare Risk Adjustment (HCC) and its impact on healthcare reimbursement.
Ability to work independently, prioritize tasks, and manage multiple projects effectively.
Excellent interpersonal and communication skills for interacting with medical professionals, coders, and other stakeholders.

Responsibilities

Review clinical documentation and medical records for accuracy, completeness, and compliance with Medicare Risk Adjustment coding requirements.
Work with physicians, providers, and healthcare teams to clarify documentation and improve the specificity of diagnoses to reflect the patient's clinical condition.
Ensure the accurate coding of all diagnoses, including chronic conditions and co-morbidities, to support Medicare Risk Adjustment (HCC) and maximize appropriate reimbursement.
Analyze and abstract relevant clinical data from patient records and ensure that ICD-10-CM codes are appropriately assigned.
Monitor and track documentation improvement metrics, providing feedback and recommendations to physicians and healthcare teams.
Conduct regular chart audits and provide education and training to clinical staff on best practices for documentation and coding.
Stay current with CMS regulations, ICD-10-CM coding updates, and risk adjustment methodologies to ensure compliance and optimal risk score capture.
Participate in multidisciplinary team meetings and collaborate with quality assurance, coding, and healthcare operations teams to improve documentation workflows.
Identify opportunities to improve documentation processes and contribute to the development of internal training programs and tools.

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