Clinical Document Specialist - Ambulatory *Days - 40hrs/wk

Requisition #: req10716

Shift: Days

FTE status: 1

On-call: No

Weekends: No

General Summary

The Clinical Documentation Specialist is responsible for reviewing the patient medical record to ensure compliant documentation supportive of ICD.10 accuracy and specificity, the capture of Hierarchical Condition Categories (HCC) and medical necessity. This position works collaboratively with the ambulatory providers and acts as a resource for educational opportunities regarding documentation guidelines and coding requirements.

Requirements

• RHIT, RHIA, CCS, CCS-P, CPC or other professional HIM coding certificate.
• Coding software and basic computer software experience.
• Effective communication and listening skills.
  
  

Essential Functions And Responsibilities

• Validates charge capture through pre-billing charge and clinical documentation review.
• Communicates with providers and other clinical staff to ensure documentation accuracy and implements documentation improvement best practices.
• Conducts follow up reviews of clinical documentation to ensure points of clarification have been recorded in the patient’s medical record.
• Identifies missing charge opportunities.
• Works in conjunction with leadership to ensure incentive program measures are documented and met.
• Participates in onboarding activities related to coding and charge capture for new employed providers.
• Maintains productivity within established departmental guidelines.
• Participates in departmental quality standards.
• Performs other duties as assigned. These may include but are not limited to: Maintaining a current knowledge base of department processes, protocols and procedures, pursuing self-directed learning and continuing education opportunities, and participating on committees, task forces, and work groups as determined by management.