Outpatient Clinical Documentation Specialist

General Summary

The Outpatient Clinical Documentation Specialist (CDS), in conjunction with physicians, coders, and clinical staff, will utilize documentation and coding expertise to facilitate the quality and completeness of medical record documentation of outpatient encounters, including but not limited to clinic visits, outpatient surgical documentation, emergency department visits, and other ancillary services. Through concurrent, prospective, and retrospective evaluation and assimilation of the medical record along with communication with physicians and other clinicians, the CDS will be responsible for achieving improved documentation results for the organization. The outcome will be documentation that accurately and completely captures the clinical picture/severity of illness/complexity of the patient while providing specific and complete information to be utilized in coding, profiling and outcomes reporting of both the facility and the physicians. The CDS utilizes knowledge of national coding guidelines (ICD-10 and CPT), Hierarchical Condition Categories (HCC), standards of compliance, and clinical knowledge to identify opportunities and to achieve results.

Education/Experience Required

• Registered Nurse (RN) CCDS, CDIP, RHIA, RHIT, CPC, CRC, or CCS; or combination thereof.
• If you are an RN and do not have CPC, CRC, or CCS it must be obtained within one year of hire.
• 3 or more years' experience either in the clinical field (RN), CDI field, (CCDS, CDIP) or coding (RHIA, RHIT, CPC, CRC, CCS) required.
• 1 or more years' experience in HCC/Risk Adjustment preferred.
• Knowledge of ICD-10 and HCC coding guidelines.
• Exemplary organizational and communication skills.
• Ability to build relationships, negotiate processes and outcomes, and influence behaviors.
• Knowledge of health care fiscal management goals and strategies, including but not limited to trends and issues in health care reimbursement, coding guidelines, and case management.
• Knowledge of electronic medical record systems and demonstrated Microsoft Office competency.
• Ability to withstand pressure of deadlines and receipt of work with variable requirements.
• Ability to work independently, be resourceful, and possess strong organizational skills.
• Ability to communicate effectively to physicians and other clinical staff; be courteous, tactful, and cooperative.
• Ability to use critical thinking and appropriate judgement throughout all phases of work.
  
  

Certifications/Licensures Required

• Registered Nurse (RN) CCDS, CDIP, RHIA, RHIT, CPC, CRC, or CCS; or combination thereof. If you are an RN and do not have CPC, CRC, or CCS it must be obtained within one year of hire.
  
  

Additional Information

• Organization: Corporate Services
• Department: Outpatient CDI
• Shift: Day Job
• Union Code: Not Applicable