Address
Form of workThe Outpatient Clinical Documentation Specialist (CDS), in conjunction with physicians, coders, and clinical staff, will utilize documentation and coding expertise to facilitate the quality and completeness of medical record documentation of outpatient encounters, including but not limited to clinic visits, outpatient surgical documentation, emergency department visits, and other ancillary services. Through concurrent, prospective and retrospective evaluation and assimilation of the medical record along with communication with physicians and other clinicians, the CDS will be responsible for achieving improved documentation results for the organization. The outcome will be documentation that accurately and completely captures the clinical picture/severity of illness/complexity of the patient while providing specific and complete information to be utilized in coding, profiling and outcomes reporting of both the facility and the physicians. The CDS utilizes knowledge of national coding guidelines (ICD-10 and CPT), Hierarchical Condition Categories (HCC), standards of compliance, and clinical knowledge to identify opportunities and to achieve results.
EDUCATION AND EXPERIENCE REQUIRED:
- Registered Nurse (RN), CCDS, CDIP, RHIA, RHIT, CPC, CRC, or CCS; or combination thereof preferred.
- Must obtain CPC, CRC, or CCS within one year of hire.
- 3 or more years experience either in the clinical field (RN), CDI field, (CCDS, CDIP) or coding (RHIA, RHIT, CPC, CRC, CCS).
- Knowledge of ICD-10 and HCC coding guidelines.
- Organization: Corporate Services
- Department: Outpatient CDI
