Clinical Documentation Improvement Specialist

PRIMARY DUTIES AND RESPONSIBILITIES:

(The below listed duties are not all inclusive. This position must also perform other duties as assigned.):

• 30%: Perform concurrent and retrospective health record reviews to identify gaps within the clinical documentation for selected facilities within a facility region
• 10%: Demonstrate proficiency in CDI regulatory requirements to include but not limited to: Documentation and Coding guidelines for professional fee-based coding: Evaluation and Management services, Procedures, and Diagnosis(es)
• 10%: Provides orientation during onboarding of new providers and scribes on documentation requirements
• 15%: Develops educational programs to providing ongoing training in response auditing findings or regulatory changes from CMS
• 15%: Provides professional advice, feedback, and education on chart documentation to providers.
• 10%: Responsible for reviewing medical record to determine documentation queries, track queries, and resolve queries
• 10%: Maintains detail results of monitoring and auditing performed with documentation of necessary education, follow up and case specific findings. Report findings at end of month to Clinical Development

JOB SPECIFICATIONS:

What specialized, technical, or practical knowledge, skills, experience, or abilities are needed to perform the job. (Include degrees, certificates, licenses, or other bona fide job qualifications.)

KNOWLEDGE/EDUCATION AND EXPERIENCE REQUIRED:

• Licensure /Certification in coding (CPC, CDIP, CCDS, CCS-P, RHIA, RHIT) required
• Demonstrate knowledge of 1995 and 1997 Evaluation and Management Documentation Guidelines and other professional documentation requirements
• Minimum of 2-3 years of experience auditing medical charts and coding required
• Demonstrate advance knowledge of critical care documentation criteria

SKILLS REQUIRED: Must be able to pass E&M skills test

• Job Knowledge: Understands the expectations of the position and consistently meets the objective of the role
• Computer experience in word processing and excel

ABILITIES REQUIRED (work characteristics, behaviors, leadership abilities, etc.):

• Productive: Completes assigned charts and reports correctly and within time allowed
• Communication: Keeps team informed and promotes open communication
• Problem Solving/Decision Making: Uses sound judgement to gather and analyze information in accordance with American Physician Partners Policies

PHYSICAL DEMANDS/REQUIREMENTS:

• Travel – light as needed to local facility
• Ability to sit for long periods of time throughout day
• Ability to work at a computer for 8+ hours