Outpatient Clinical Documentation Specialist

About the role

The Outpatient Clinical Documentation Specialist assists the hospital with processes for complete and accurate capture of documentation and charges for outpatient services. They provide education and training on clinical documentation, coding, and charging, conduct chart reviews, and coordinate with clinical departments to resolve missing charges.

Responsibilities

• Supports accurate documentation and charging in compliance with company policies
• Reviews and educates clinical departments on documentation, medical necessity, coding, and charging
• Conducts shadowing and coaching with key stakeholders to foster adoption of best practices
• Performs analysis of patient clinical and billing data to identify opportunities for improvement
• Works with finance to track revenue indicators and develop action plans
• Reviews accounts for potential missing documentation, coding, and charging
• Identifies root causes of missing charges and educates clinical and ancillary departments
• Coordinates with clinical departments, coding, CDM, and other stakeholders to address and resolve root cause issues
• Audits and monitors defined areas
• Performs process improvement activities aimed at revenue optimization

Requirements

• Bachelor’s degree or 5+ years of related healthcare experience
• RN, LPN, RHIA, RHIT, CPC, COC, or CDEO credential preferred
• Experience in healthcare knowledge, preferably from a clinical caregiver, manager, coding specialist, or revenue management/cycle professional background
• Knowledge of APC and OPPS reimbursement structures preferred
• Strong project management skills
• Strong interpersonal skills, effective communication, and problem-solving abilities
• Proficiency with electronic medical records (EPIC preferred) and hospital billing functions
• Effective organizational skills and ability to prioritize multiple tasks
• Ability to work independently or within a team structure

Qualifications

• General understanding of hospital-based outpatient charging, coding, and/or revenue capture functions
• Good manual and finger dexterity
• Physical presence onsite is essential