Clinical Documentation Improvement Spec – Outpatient

This is a fully remote position, open to applicants in North Carolina.

📋 Description

• Conduct pre-visit and retrospective assessments of outpatient medical records.

• Recognize areas for enhancing provider documentation and engage with physicians when necessary.

• Ensure that documentation accurately reflects HCC capture, ICD-10-CM precision and specificity, along with medical necessity.

• Evaluate patients’ clinical conditions, treatment plans, and medical histories to pinpoint documentation deficiencies.

• Provide education to physicians, advanced practice providers, and healthcare professionals on the importance of accurate, specific, and comprehensive clinical documentation.

• Present provider-specific metrics and mentor providers on closing gaps related to problem lists and RAF.

• Collaborate with clinic personnel, coding teams, compliance experts, and clinical documentation analysts.

• Analyze data and trends, discover opportunities, propose solutions, and engage in resolution efforts.

• Participate in select committees and contribute to educational programs.

• Stay updated on HCC documentation standards, ICD-10-CM code assignment, and coding regulations.

• Execute other assigned responsibilities.

⛳️ Requirements

• A BSN, PA, NP, or a doctoral degree in a medically related field is required.

• A minimum of 3 years of relevant experience is necessary.

• Current licensure as an RN, NP, PA, or in the specific medical field related to the doctoral degree is essential.

• A current Clinical Documentation Improvement certification (CDIP, CCDS, CCDS-O, or CDEO) is highly preferred, or obtaining an appropriate certification within 2 years of employment.

• Certification in medical coding or risk adjustment (CRC, CPC, CCS, CCS-P, or other relevant outpatient certifications) is preferred.

• Comprehensive knowledge of outpatient CDI and risk-adjustment coding.

• Strong written and verbal communication, presentation, and training abilities.

• Excellent analytical thinking, innovative problem-solving, and conflict-resolution skills.

• Strong organizational and planning capabilities.

• Proficient in computer skills and statistical reporting.

• Familiarity with PowerPoint, Excel, 3M software, and Encoder.

• Proven understanding of quality improvement theories and practices.

• Ability to work autonomously with minimal oversight.

• Ambulatory nursing or clinical experience is preferred.

• Experience with Medicare risk adjustment, HCCs, coding, billing, or auditing is preferred.

🏝️ Benefits

• Relocation Assistance (subject to eligibility).

• A one-time commitment bonus of $7500, distributed in two equal installments over 12 months in 6-month increments.

• Opportunities for continuing education.

• An Affirmative Action/Equal Opportunity employment environment.

• Provisions for reasonable accommodations.