Clinical Documentation Improvement Specialist

Conduct Risk Adjustment Reviews of medical records, patient medical history and physical exams, physician orders, progress notes, consultation reports, diagnostic reports, operative and pathology reports, and discharge summaries to verify whether:

• The diagnosis codes are supported by the documentation and ensure with ICD-10-CM Guidelines for Coding and Reporting.
• The diagnosis codes for each chronic or major medical condition have been captured correctly.
• Review for clinical indicators and query providers to capture the severity of illness of the patient.
• Conduct medical chart review to identifying opportunities for improving individual member risk adjustment score accuracy and communicate the same to the physician or his /her designee.
• Obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers
• Educate practice office physicians and staff on clinical documentation needs, changes to clinical documentation guidelines and coding issues.
• Conduct follow up review of clinical documentation to ensure proper clinical information is documented in the patient’s record.
• Generate accurate and timely status reports for physicians & leadership.
• Performs other work related duties as assigned or requested.

Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects Cape Cod Healthcare’s commitment to CARES: compassion, accountability, respect, excellence and service.

Associate’s Degree in a relevant field preferred or combination of equivalent education and experience.

• Knowledge of clinical documentation guidelines and CDI program implementation

experience preferred.

• Certified Professional Coder (CPC) certification required.
• Knowledge of disease process, medical terminology, ICD-10-CM and CPT codes.
• Knowledge of ICD-10 principles and further documentation specificity highly preferred.
• CCDS or CDIP in an active status with AHIMA or ACDIS is preferred.
• Excellent organizational, analytical, writing and interpersonal skills.
• Dependable and self-directed.
• Critical thinking, problem solving and deductive reasoning skills.
• Proficient computer skills – familiarity with Windows based software programs.
• Knowledge of Medicare Part A and Part B.
• Knowledge of regulatory environment.
• Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers.
• Management/supervisory experience preferred.