Outpatient Clinical Documentation Specialist

Job Address:

POSITION SUMMARY:
The Risk Adjustment Clinical Documentation Specialist (CDS) will provide clinically based prospective, concurrent, and retrospective reviews of medical records of members enrolled in value-based agreements to evaluate risk adjustment capture based on clinical documentation. The CDS will review risk adjustment gap lists for members, including suspect conditions, and perform chart reviews to determine provider query opportunities and provider coding education opportunities.  The CDS will utilize Physician documentation queries to communicate clinical indicators to Physicians/Other Qualified Health Care Providers in preparation for upcoming visits. The Risk Adjustment CDS will work collaboratively with clinical reviewers to determine the validity of clinical indicators in provider CDI queries and obtain clinical feedback for CDI process improvement. The goal of the CDS includes facilitation of appropriate physician documentation of care delivery to accurately reflect patient severity of illness and risk of mortality. Additionally, the CDS supports all Coding initiatives within the MSO to ensure compliant revenue capture in risk adjustment methodology and fee-for-service claims. Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement. Additional duties as assigned by Coding Leadership.

JOB REQUIREMENTS

EDUCATION/CREDENTIAL:

• Bachelor’s degree in nursing or health information management preferred, however, an equivalent combination of education and experience in CDI and coding, which provides proficiency in the areas of responsibility, may be substituted for the stated education and experience requirements.
• CRC Required. 
• Additional medical auditing credentials are required: CPMA, CDEO, CCDS, CCDS-O 
• Preferred in addition to coding and auditing credentials: Clinical credential of RN, LPN, or IMG.  In the absence of clinical credentials, a suitable candidate must have coding credentials that include a CRC and medical auditing credentials specified above as well as education in medical terminology, pharmacology, and pathophysiology

EXPERIENCE:

• Required: Minimum 5 years related experience working in Risk Adjustment Validation including prospective documentation reviews and pre-visit planning. 
• Required: Minimum of 3 years of experience in addition to Risk Adjustment either concurrently or sequentially, working in fee-for-service coding and auditing including CPT, E&M, modifiers, NCCI, LCD/NCD, and procedural documentation integrity and education. 
• Preferred: Experience in developing and delivery of coding education, peer training, peer quality assurance, and workflow management

KNOWLEDGE AND SKILLS:

• Knowledge of care delivery documentation systems and related medical record documents.
• Knowledge of age-specific needs and the elements of disease processes and related procedures.
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes, medical terminology, and pharmacology
• Excellent written and verbal communication skills.
• Excellent critical thinking skills.
• Excellent understanding of Compliant Query processes in Risk Adjustment/Outpatient CDI.
• Excellent understanding of ICD10CM coding and guidelines
• Excellent understanding of CPT and E&M coding
• Excellent understanding of risk adjustment methodology and value-based care objectives.
• Demonstrated employee and medical staff relationships in the past and has the ability to maintain those going forward.
• Ability to work independently in a time-oriented environment.
• Computer literacy and proficiency with Microsoft 365 and basic office equipment.
• Competency in tracking outcomes of risk adjustment/CDS activities.
• Ability to collaborate in cross-functional teams, with clinicians, peers, and leadership.
• Ability to perform quality assurance reviews for peer education.
• Ability to identify documentation improvement trends and educational opportunities to ensure clinical documentation education teams have all data needed to effectively provide education to their peers.
• Leadership skills and qualities.
• Ability to adapt to changes in the workload, to work independently and effectively prioritize work assignments