Clinical Documentation Specialist (Greater Houston Residents)

We are a dynamic, quickly-growing company based in Greater Houston, TX area. We provide medical billing services to numerous healthcare facilities in an effort to allow the physicians and nursing staff to focus on providing quality care to their patients.

We are seeking a dynamic Clinical Documentation Specialist, to join our team!

The Clinical Documentation Specialistis responsible for training, performing audits and reviewing Clinical Documentation, physician billing records. They will conduct internal reviews of documentation accuracy, policies, and procedures to ensure an efficient liability free operation.

Tasks:

• Identify and resolve Clinical Documentation and charge capture discrepancies to improve quality of the Clinical Documentation, severity and reimbursement levels assigned, integrity of charges data reported.
• This role also facilitates modifications to Clinical Documentation through extensive interaction with physicians, nursing staff, other patient care givers, and medical records coding staff to ensure that appropriate reimbursement is received for the level of service rendered to all patients.
• Demonstrates knowledge of DRG payor issues, optimization strategies, Clinical Documentation requirements and referral policies and procedures.
• Requests clarification and/or correction from physicians for unclear diagnoses, complications, procedures, and clinical information.
• Assist with implementation and training of physicians upon opening of new facilities
• Knowledge and experience with evaluation and management emergency medicine, observation, and inpatient coding and documentation.
• Identify clinical document improvement opportunities for clinical staff
• Provide education and training for clinical staff.
• Performs medical necessity checks appropriately utilizing the CMS website for Medicare to provide feedback to clinical staff on audit results and provide training on areas where documentation compliance is not met.
• Maintain ongoing communication with management, physicians, and other revenue departments to ensure compliance.
• Perform other duties as assigned
• Travel may be required.

Knowledge, Skills, and Abilities:

• Knowledge of and experience using ICD 10, PCS, CPT, and HCPCS coding.
• Knowledge of payor guidelines
• Knowledge of and skill in using personal computers in a Windows environment with an emphasis on basic word processing and data entry.
• Ability to work independently and make decisions
• Ability to pay close attention to detail.
• Ability to identify research and solve problems and discrepancies.
• Ability to communicate with employees, management, and physicians in a courteous and professional manner.
• Ability to process assigned duties in an organized manner.

Education & Certifications:

• Outpatient or Professional Fee Coding Certifications: Register Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Certified Coding Specialist - Professional (CCS-P) or Certified Professional Coder – Hospital (CPC-H)
• Inpatient Coding Certifications: Registered Health Information Technician (RHIT), Certified Inpatient Coder (CIC), or Certified Coding Specialist (CCS)
• High School Diploma (or GED or High School Equivalence Certificate), Associate or Bachelor’s degree preferred
• Clinical Documentation: Certified Clinical Documentation Specialist (CCDS)