Senior Consultant - Clinical Documentation Specialist

Work you’ll do

• Analyze medical records for inpatient and outpatient service areas for accuracy of coding and documentation to ensure regulatory compliance
• Apply knowledge of medical terminology, disease conditions and procedures to evaluate clinical documents
• Monitor diagnoses, treatments, and follow-up entries in medical records to lead to coding accuracy
• Identify gaps in clinical documentation and request missing information from the appropriate providers
• Develop and implement plans for both formal and informal education of physicians, CDI team, health information management and other clinical staff
• Develop in-service education tools as necessary for physicians, CDI team and ancillary staff and assist physician champion to conduct education as needed
• Train CDI team, physicians and other medical staff on suitable documentation processes to ensure consistency and accuracy of clinical documentation
• Interpret and prepare clinical reports for healthcare professionals, executives and other stakeholders to discuss documentation trends, outcomes and go forward plans
• Meet with healthcare stakeholders to explain findings and facilitate actions based on recommendations
• Participate in and facilitate executive meetings to explain CDI benchmarks, KPIs and demonstrate overall program accomplishments and challenges through analytics and dashboards
• Conducts and monitors the provider education to ensure appropriate and timely usage of face-to-face meetings, conference calls, Web Conferencing and group facility meetings
• Create and deliver presentations at local and national conferences and/or client meetings
• Keep up to date with advancements changes in regulations pertaining to coding, clinical documentation and health information technology

Required Qualifications

• Bachelor’s degree in nursing, medical degree, or physician assistant required
• Current Registered Nurse (RN) license required
• Certified Clinical Documentation Specialist – CCDS (inpatient) certification required.
• A minimum of 3 years of experience in acute inpatient settings
• Extensive experience in collecting, interpreting and communicating medical information to select appropriate clients with recommendations and plan of action
• Knowledge of care delivery documentation systems and related medical record documents
• Knowledge of age-specific needs and the elements of disease processes and related procedures
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes
• Strong analytical skills
• Ability to keep up to date with advancements and regulations in medical coding and clinical documentation
• Proficient in MS Word, Excel and PowerPoint preferred
• Proficient in Electronic Medical Record (EMR) software, such as Epic, Cerner, Allscripts, etc. required
• Excellent verbal and written communication skills with small and large group presentation skills
• Ability to work independently and with multiple teams in a time-sensitive environment
• Ability to travel 50-70%, on average, based on the work you do and the clients and industries/sectors you serve.
• Must be legally authorized to work in the United States without the need for employer sponsorship, now or in the future.

Preferred Qualifications

• Master’s degree in Clinical Informatics, Business Administration, Nursing and related health fields preferred
• Case Management or Medical coding certification a plus (CRC, CCA, CCS-P, CCS, CPC, CDIP, CCM)
• Experience as clinical registered nurse, physician, physician assistant, case manager, clinical documentation specialist, utilization review, informatics RN, Quality, DRG Validation and health IT preferred
• Knowledge of Medicare reimbursement system and coding structures preferred
• In-depth knowledge and experience in medical terminology, medical coding, and ICD-10-CM/PCS, IPPS payment system is a plus
• Experience in quality measurement, quality improvement, and value-based payment models
• Proven applicable CPT and ICD-10 coding experience; APR-DRG, MS-DRG and HCC assignment
• Other revenue cycle experience including conducting charge capture and coding reviews for compliance with billing and coding regulatory requirements
• Experience in program and/or project management for technology implementations using third party software
• Knowledge of process excellence (Six Sigma, LEAN, Design Excellence), certifications preferred
• Experience training, educating and coaching