Outpatient Clinical Documentation Improvement Specialist

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

📋 Description

• Accountable for conducting concurrent reviews of patient records to guarantee comprehensive, accurate, and specific clinical documentation.

• Must possess a thorough understanding of Coding Guidelines and be tasked with clarifying any conflicting, incomplete, or vague documentation by actively pursuing solutions and educating providers.

• Aim to continually enhance clinical documentation to accurately represent the care delivered and the corresponding reimbursement.

• Responsible for elevating the overall quality and completeness of clinical documentation.

• Facilitate alterations to clinical documentation through extensive concurrent engagement with physicians, nursing staff, other patient caregivers, and Physician Practice Coding staff to ensure that appropriate reimbursement, clinical severity of illness, and risk of mortality are accurately captured for the level of service provided to all patients.

• Aids in the timely, accurate, and complete documentation of clinical information utilized for measuring and reporting physician and practice outcomes.

• Provides ongoing education to all members of the patient care team.

⛳️ Requirements

• Must hold an Associate’s degree in Healthcare, Nursing, or a related field, or possess an equivalent combination of education and experience.

• Must have training in medical terminology, anatomy, and physiology.

• Must have training and certification in coding, or an equivalent combination of education and experience.

• Must possess a certification; Certified Documentation Expert Outpatient (CDEO), Certified Clinical Documentation Specialist-Outpatient (CCDS-O), or Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) with experience in coding or clinical documentation integrity.

• Must agree to obtain CDEO or CCS-O within the first year of employment.

• Extensive knowledge of medical record content is required.

• Comprehensive knowledge of coding/classification systems (ICD & CPT) and related coding guidelines is necessary.

• Experience in compliant healthcare documentation, HCC coding requirements, and alternate payment models within a multi-facility, revenue cycle environment.

• Basic computer skills are essential.

• Familiarity with coding software (encoders) is preferred.

• Should be knowledgeable in LDC/NCD (or how to research this) and Quality Measures.

• Understanding of coding guidelines is important.

• Requires excellent observational skills, analytical thinking, problem-solving abilities, along with superior verbal, written, and presentation skills.

• Must demonstrate the ability to manage and prioritize multiple tasks, projects, and requests while meeting deadlines.

• Effective communication via remote Teams application is necessary.

• Manual and finger dexterity are required.

• Ability to sit for extended periods of time is necessary.

• Willingness to travel to provider practices or group meetings as needed.

• Requires corrected vision and hearing within the normal range.

• Must be able to work under stressful conditions.

• Excellent interpersonal skills are essential for interactions with co-workers, providers, physicians and their office staff, Practice Managers, and other work areas.

🏝️ Benefits

• Health insurance

• Retirement plans

• Paid time off

• Flexible work arrangements

• Professional development opportunities