Outpatient CDI Specialist-1

About the Role

The Outpatient CDI Specialist is a hybrid role that combines the expertise of clinical documentation improvement (CDI) and outpatient Hierarchical Condition Category (HCC) coding. This position focuses on improving the accuracy, quality, and completeness of clinical documentation in outpatient medical records while ensuring compliance with coding guidelines. The specialist will work collaboratively with providers, coding teams, and other healthcare professionals to facilitate accurate coding, improve risk capture, and optimize reimbursement while reflecting the true severity of illness and care provided.

Qualifications

• High School Diploma or equivalent; associate or bachelor's degree in nursing required.
• Bachelor's degree in nursing from an accredited school of nursing and at least five years' clinical nursing experience preferred.
• Licensure as a registered nurse by the South Carolina Board of Nursing or compact state.
• Registered Nurse (RN) with at least 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.
• Minimum of 3 years of experience in clinical documentation improvement, outpatient Hierarchical Condition Category (HCC), or a combination of both, preferred.
• Experience in an outpatient or acute care setting required.
• Active certification from one of the following:
  • AAPC (Certified Professional Coder - CPC, or Certified Documentation Expert – Outpatient CDEO)
  • AHIMA (Certified Coding Specialist – CCS or Certified Documentation Improvement Practitioner – CDIP)
  • ACDIS (Certified Clinical Documentation Specialist - CCDS or CCDS-O)
• Candidates without a certification must obtain one within the first year of employment.
• Proficiency in ICD-10-CM, CPT, and E/M coding guidelines.
• Strong clinical experience and critical thinking skills.
• Extensive knowledge of patient care, clinical measurement tools, and clinical outcomes.
• Ability to establish cooperative working relationships with diverse groups and individuals, medical staff, and other healthcare disciplines.
• Ability to work independently, be resourceful, and possess strong organizational skills.
• Ability to communicate effectively with physicians and other clinical staff; be courteous and professional.

Responsibilities

Clinical Documentation Improvement (50%)

• Conduct concurrent reviews of medical records to ensure clinical documentation captures the full scope of patient severity, risk of mortality, and medical necessity for outpatient services.
• Collaborate with physicians, nurse practitioners, case managers, and coders to identify opportunities for improving documentation of diagnoses, procedures, and medical necessity.
• Query providers in a compliant and clear manner to address documentation gaps, ambiguities, or discrepancies to support accurate coding and billing.
• Educate providers and clinical staff on best practices for documentation to improve outpatient encounter accuracy and quality.

Outpatient HCC Coding (25%)

• Accurately assign ICD-10-CM and CPT codes for outpatient encounters, including clinical visits, emergency department visits, ambulatory surgeries, laboratory services, and observation care.
• Abstract data and input into electronic medical record systems while adhering to organizational and regulatory coding standards.
• Ensure coding accuracy meets or exceeds a 95% accuracy rate, following official ICD-10-CM and CPT guidelines.
• Collaborate with revenue cycle and HIM teams to address coding denials, documentation issues, and billing discrepancies.

Data Integrity and Compliance (15%)

• Maintain complete confidentiality of patient information and adhere to HIPAA regulations and organizational policies.
• Ensure documentation and coding practices meet compliance standards for regulatory and payer requirements.
• Perform audits and provide feedback to improve documentation and coding practices within outpatient settings.

Collaboration and Education (10%)

• Act as a liaison between clinical providers and HIM to bridge the gap between documentation and coding requirements.
• Provide training and educational sessions for providers on coding and documentation standards, focusing on outpatient services.
• Participate in ongoing education and stay current with changes in coding guidelines, CDI practices, and healthcare regulations.

Physical Requirements

Mobility & Posture

• Standing: Continuous
• Sitting: Continuous
• Walking: Continuous
• Climbing stairs: Infrequent
• Working indoors: Continuous
• Working outdoors (temperature extremes): Infrequent
• Working from elevated areas: Frequent
• Working in confined/cramped spaces: Frequent
• Kneeling: Infrequent
• Bending at the waist: Continuous
• Twisting at the waist: Frequent
• Squatting: Frequent

Manual Dexterity & Strength

• Pinching operations: Frequent
• Gross motor use (fingers/hands): Continuous
• Firm grasping (fingers/hands): Continuous
• Fine manipulation (fingers/hands): Continuous
• Reaching overhead: Frequent
• Reaching in all directions: Continuous
• Repetitive motion (hands/wrists/elbows/shoulders): Continuous
• Full use of both legs: Continuous
• Balance & coordination (lower extremities): Frequent

Lifting & Force Requirements

• Lift/carry 50 lbs. unassisted: Infrequent
• Lift/lower 50 lbs. from floor to 36”: Infrequent
• Lift up to 25 lbs. overhead: Infrequent
• Exert up to 50 lbs. of force: Frequent

Vision & Sensory

• Maintain corrected vision 20/40 (one or both eyes): Continuous
• Recognize objects (near/far): Continuous
• Color discrimination: Continuous
• Depth perception: Continuous
• Peripheral vision: Continuous
• Hearing acuity (with correction): Continuous
• Tactile sensory function: Continuous
• Gross motor with fine motor coordination: Continuous
• Olfactory (smell) function: Continuous

Work Environment & Conditions

• Effective stress management: Continuous
• Rotating shifts: Frequent
• Overtime as required: Frequent
• Latex-safe environment: Continuous
• Respirator use qualification: Continuous

Scheduled Weekly Hours: 40