BASIC PURPOSE OF THE JOB
The Professional Clinical Documentation Specialist (CDS) will serve as an advisor and expert resource for providers to improve the accuracy of clinical documentation to support patient complexity and appropriate E/M levels thereby supporting the provider’s efforts and their professional fee billing.The CDS primarily assist providers in identifying clinically relevant information and capturing the clinical documentation needed to accurately reflect patient acuity. They will also assist with highlighting opportunities based on the provider’s medical decision making to appropriately reflect the level of service provided for patient care.The Professional CDS will be responsible for completing post-claim reviews as well as providing clear communication and education to providers on their documentation, coding and billing practices, in adherence to compliance standards set by governing entities such as CMS, AHA, etc.
REPORTS TO
- Director of Health Information Management
JOB REQUIREMENTS
Supervisory Responsibilities: NO
Minimum Education: Minimum associate degree
Degree: Associate’s degree in a health-related field
License/Certification Required: CCS-P, CPC, or other coding credential. RN or LPN helpful but not required.
Minimum Work Experience: 2 years in coding or health related field.
REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES
- Clinical knowledge and understanding of pathophysiology and pediatric conditions, preferred
- Strong critical thinking skills and utilization of clinical knowledge to identify potential clinical indicators supporting patient acuity and clarifications of the medical record
- Excellent written and verbal communication skills
- Possesses strong project management skills
- Possesses strong interpersonal skills, with demonstrated success at communicating effectively with all levels of the organization
- Ability to work independently in a time-oriented environment
- Demonstrates skilled ability and comfort with electronic medical records (EPIC preferred)
- Proficient with personal computer applications (Excel, Word, and Power Point)
- Ability to build education material that is meaningful for providers and team members
- Strong problem solving and investigative skills
DUTIES AND RESPONSIBILITIES
- Coordination with Professional Services CDI Program leadership and colleagues. Fosters teamwork and utilizes strong team building measures
- Applies a “clinical detective” mindset to perform post-claim reviews focused on appropriate E/M level assignments and any opportunities related to level of service and diagnostic conditions.
- Uses performance and outcome data from third-party support or other sources to identify high priority providers
- Creates specialty-specific education on relevant topics as identified in data analytics and from clinical encounter reviews and post-claim education chart reviews
- Develops and maintains a systematic education schedule and approach for providers in the hospital and clinic/office setting including but not limited to complete documentation, appropriate diagnosis code selection, E/M level assignments and updates to coding guidelines.
- Delivers ongoing feedback and education to communicate importance of complete documentation and key concepts during regular clinic or provider meetings or on individual basis, as needed
- Upholds working knowledge and stays current on latest CMS and industry guidelines, and implications for documentation
- Maintains strict confidentiality of all patients, employee and physician information according to HIPAA guidelines
- Shares in organization’s vision, demonstrates its values, supports its philosophy and is sensitive to its mission. Demonstrates knowledge of and follows departmental and hospital policies and physician office procedures
- Seeks out opportunities for individual growth and development, including attending various meetings, conferences, courses, seeking certifications, as required.
- Uses tact and sensitivity when communicating with patients, visitors, co-workers, and other personnel
- Serves on department and/or institutional committees as requested
- All other duties as assigned
PHYSICAL REQUIREMENTS-Note: Reasonable accommodations may be made for individuals with disabilities to perform the essential functions of this position.
- Light lifting, pushing and pulling is required for 10-20 lbs occasionally and frequent moving of objects of less than 10 lbs is required. Frequent sitting with some walking, standing, squatting, bending and reaching is required. Keyboard/computer use and/or repetitive motions may be required.
Come work where you can make a difference everyday.