Specialist, Clinical Documentation Improvement

ArchWell Health • Nashville, TN

3d • Hybrid

About The Position

The Clinical Documentation Improvement Specialist (CDIS) uses clinical knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record. The CDIS works collaboratively with outpatient physicians and advanced practice providers to ensure that the clinical information within the medical record is accurate, complete, and compliant and supports accurate coding. This includes accurate documentation to support the capture of Hierarchical Condition Categories (HCCs) and ICD-10-CM specificity in outpatient visits. The CDIS functions as an SME resource and provides education to members of the patient care team both formally and informally regarding the impact of documentation on patient care, quality metrics, and accurate disease burden reporting.

Requirements

• Ability to work both autonomously and within the team – innovation and collaboration is a priority
• Ability to travel –travel required minimum one (1) week per month (Monday - Friday) to assigned clinical site(s)
• Experience with an Electronic Medical Record (EMR) system(s)
• Knowledge of, but not limited to, current coding guidelines and methodologies including CMS HCC models, ICD-10-CM coding guidelines and conventions
• Extensive knowledge of medical terminology, anatomy and pathophysiology, pharmacology, and ancillary test results
• Strong organization and analytical thinking skills – detail oriented
• Proficient with Microsoft Office applications (Outlook, Excel, PowerPoint)
• Demonstrates critical thinking skills, able to assess, evaluate, and teach
• Self-motivated and able to work independently without close supervision
• Strong communication skills (interpersonal, verbal and written)

Nice To Haves

• CCS, CPC, CRC or similar coding certification
• Three (3+) years HCC/Risk Adjustment coding/documentation experience
• Previous outpatient CDI experience

Responsibilities

• Facilitate appropriate clinical documentation through concurrent, prospective, and retrospective medical record review.
• Ensure documentation in the medical record follows the official coding guidelines and internal guidelines.
• Use clinical knowledge to identify potential gaps in clinical documentation.
• Provide ongoing feedback to physicians and other providers regarding coding guidelines and documentation requirements.
• Assist with education of physicians, other providers, and clinic staff relating to clinical documentation compliance as well as new policies and procedures related to coding.
• Maintain competence related to HCC documentation requirements, ICD-10-CM code assignment, and coding and reporting guidelines.
• Travel to assigned outpatient centers to provide availability for inquiries and present education materials to provider groups.
• Provide both formal and informal education to physicians, advanced practice providers, and other key healthcare providers regarding clinical documentation updates and present chart review findings.

What This Job Offers

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