Senior Remote Clinical Documentation Specialist

Job Description

The Clinical Documentation Specialist Senior is responsible for facilitating the improvement in the overall quality and completeness of provider-based clinical documentation in the medical record by working directly with providers. This position is responsible for assisting treating providers to ensure that documentation in the medical record accurately reflects the severity of illness, risk of mortality, complexity of patient care, and hierarchal condition categories of the patient. This position will recognize opportunities for documentation improvement and hold collaborative discussions with providers.

Essential Job Duties

• Performs extensive record review
• Reviews medical records for quality, completeness, and accuracy of documentation
• Ensures that coded diagnoses accurately reflect level of patient care and patient status, including severity of illness and risk of mortality
• Identifies gaps in documentation as well as conflicting or unspecified diagnoses and clarifies diagnoses with providers to assign the most accurate ICD 10CM/PCS code from the documentation
• Maintains quality and productivity measures established per policies
• Works independently when reviewing each case, utilizing clinical judgement to determine when to contact the provider or inpatient coders
• Delivers ongoing education to providers through collaboration and communication via zoom meetings, telephonic discussions, and email
• Provides supplemental educational material and tools relative to documentation improvement practices for individual practitioners and groups of clinicians
• Applies knowledge of standards and regulations while educating the physicians on different topics
• Identify and share documentation improvement opportunities with providers to capture the patient's accurate severity of illness and risk of mortality, comorbid conditions, and all other condition categories
• Utilizes a combination of clinical knowledge and coding skills to develop clear, concise and compliant written and verbal queries to providers, seeking clarification on unclear, incomplete, or non-specified documentation
• Completes extensive independent research to be complaint while sending queries, interpret and abide by the governing bodies AHIMA and ACDIS and be up to date with the coding changes and updates occurring every April and October
• Reports clinical documentation improvement metrics Key Performance Indicators and additional significant metrics will be reported and discussed regularly, and as needed to the Medical Executive Committee via presentation to the Medical Records Committee and with other committees as directed
• Functions as a subject matter expert for the team and assists less experienced team members in following operational policies
• Responsible for training and onboarding new team members
• Participates in special projects assigned by the Mid Revenue Cycle leadership

Minimum Skills/Specialized Training

• Proven record of combining clinical knowledge and coding skills
• Ability to recognize opportunities for documentation improvement and hold collaborative discussions with providers to address the opportunities in documentation
• Proficient in computer skills including MS Office, Optum 360 eCAC, Cerner EHR
• Organized, analytical, superior interpersonal and writing skills
• Dependable, self-directed with critical thinking, problem solving, and deductive reasoning
• Knowledge of healthcare regulatory environment
• Understand and support clinical documentation management strategies
• Must be flexible to accommodate clinician schedules
• Knowledge of Case Mix Index and how it is influenced

Qualifications

• Associate’s degree required; Bachelor’s preferred – Nursing, HIM, or another Healthcare related field
• A minimum six (6) years' acute care clinical documentation experience to include:
• Applying Medicare, Medicaid and Commercial payer regulations, charging and coding guidelines
• Healthcare regulations
• ICD-10-CM, ICD-10-PCS coding
• Performing independent queries
• For Minimum Skills/Specialized Training, describe the particular skills, knowledge and abilities required, as well as the depth and/or breadth of those competencies.
• For Minimum Experience, describe the minimum length (use specific number of years, not a range) and type of work experience required to successfully perform the job.
• Preferred Experience 4 years' experience in oncology Vizient experience