"Clinical Documentation Spec"

Job Description

The Clinical Documentation Specialist (CDS) is responsible for applying their knowledge of medical terminology, risk adjustment, and coding to ensure appropriate capture of diagnoses based on coding guidelines and identify gaps and opportunities within ambulatory settings. They are responsible for planning, coordinating, and providing education to faculty, APPs, and house officers related to Hierarchical Condition Categories (HCC). Develop and implement an education plan to communicate the principles and importance of accurate and complete documentation within the electronic health record (EHR). Serve as a resource of documentation guidelines and regulatory requirements and updates. Partner with and maintain strong collaborative relationships with the Medical Director, Physician Champions, UMMG Department Clinical Documentation Specialists (CDS), and Revenue Quality Liaisons (RQL). Understand and articulate data and analysis clinical documentation and risk adjustment coding trends.

Core Responsibilities and Expectations:

• Responsible for outpatient Hierarchical Condition Category (HCC) pre-visit and post-visit reviews and makes corrections when needed to ensure accurate and specific capture of chronic conditions, comorbidities, and risk-adjusting diagnoses based on coding guidelines.
• Collaborate with providers to clarify and enhance documentation through compliant queries, education, and feedback.
• Serves as a source of contact and resource for faculty, APPs, and house officers regarding clinical documentation and medical coding for patient care services.
• Prepare reports to provide feedback on provider performance including HCC documentation and coding. Including specialty specific documentation examples and power point presentations to be shared at department meetings, as requested.
• Identifies HCC pre-visit and post-visit documentation trends to be shared with the Physician Champion to allow for clinician education.
• Educate clinicians on risk adjustment models, disease hierarchies, evaluation and management and documentation standards of excellence through one-on-one sessions, tip sheets, new provider onboarding, and group training.
• Develop tools (ex. Education materials, learning modules, training videos, etc.) which assist providers with efficient, effective documentation and accurate billing.
• Serves as a resource for documentation requirements and ensures compliance with applicable laws and regulations.
• Assist with compliance initiatives related to risk adjustment documentation.
• Partners with the RQL and follow-up to units within Revenue Cycle and ensure consistent communication between all parties.
• Maintains current with specialty coding updates, work processes, tools, and clinical and administrative applications necessary to perform job functions.
• Project a professional and positive image when interacting with patients, faculty, and staff.
• Performs other duties appropriate to the CDS function, as assigned

Department Specific Responsibilities and Expectations:

• Responsible for outpatient Hierarchical Condition Category (HCC) pre-visit and post-visit reviews and makes corrections when needed to ensure accurate and specific capture of chronic conditions, comorbidities, and risk-adjusting diagnoses based on coding guidelines.
• Conduct special review requests to assess compliance risk and identify areas of opportunity for improvement in coding and billing practices. Conduct post-review group and individual training and education.
• Develop and present issue-specific and general revenue cycle presentations to large groups, including faculty meetings, provider orientation sessions, etc.
• Onboard new faculty and advance practice providers with compliance training via on-line training tools.
• Research, interpret and communicate applicable laws and regulations, and third-party payer rules.
• Keep providers informed of rapidly changing regulatory and third-party payer billing rules; serve as a liaison with the clinical departments in the areas of coding and documentation for their specialties.
• Perform focused analytical documentation and coding reviews to proactively assess compliance and revenue loss risks for areas of concern identified by the Revenue Cycle Compliance and Education office.
• Participate in management of the Revenue Cycle compliance work plans, including identifying and assessing issues that create risk for the Health System.
• Collaboration with the Health Information Management (HIM) team on joint projects related to quality measures and best practices in documentation impacting both facility and professional billing.
• All other duties as assigned.

Supervision:

The Revenue Cycle Compliance Provider Educator will be supervised by the Manager of the Provider Education team in the Revenue Cycle Compliance Division. The CDS does not have supervisory responsibilities.

Required Qualifications:

• Associate degree or equivalent
• At least five years of medical coding experience
• Current RHIT, RHIA, CPC, or CRC certification
• Demonstrated experience providing clinical documentation and coding education to providers.
• Excellent communication skills (verbal and written) to enable effective outcomes with the diverse complex clinical care teams.
• Ability to navigate the EHR to identify documents for review to provide accurate capture of clinical information.
• Extensive CPT and ICD-10 coding knowledge.
• Medical terminology and clinical knowledge with the ability to review documentation and determine what documentation is needed to provide accurate medical codes.
• Ability to work independently, self-motivated and ability to adapt to the changing healthcare environment.
• Proficiency in organizational skills and planning with an ability to juggle multiple priorities in a fast-changing environment.
• Proficiency in computer use including Microsoft Office Suite experience.
• Provide support to clinicians on navigating the EHR to make addendums, create SmartTexts and SmartPhrases and utilize templates.
• Attention to detail with thoroughness and accuracy when accomplishing a task.
• Possess proactive, strategic, innovative and out-of-the-box thinking.
• This is a Hybrid/Remote position.

Desired Qualifications:

• Bachelor’s degree in health information management or other healthcare related fields.
• Knowledge of HCC coding and Risk Adjustment Credential from AHIMA or AAPC
• Demonstrated understanding of Evaluation and Management (E&M), Surgery and Minor procedure coding, billing, and documentation
• Certification in healthcare compliance through Healthcare Compliance Association (HCCA).
• Experience performing reviews, analyzing documentation, and identifying areas of risk and potential irregularities across the revenue cycle.
• Experience interpreting and applying CMS and other third-party payer guidelines and regulations, particularly related to professional services and teaching physician rules.
• Ability to communicate complex policies and regulations to multiple audiences.