Employee Type:
Regular
Work Shift:
Day - 8 hour shift (United States of America)
Join Team Tidelands and help people live better lives through better health!
Clinical Documentation Improvement Specialist (RN) (3419)
Are you passionate about quality and committed to excellence? Consider joining our Tidelands Health team. As our region's largest health care provider, we are also one of our area's largest employers. More than 2,500 team members at more than 70 Tidelands Health locations bring our healing mission to life each day.
A Brief Overview
The Outpatient CDI Specialist is a hybrid role that combines the expertise of clinical documentation improvement (CDI) and outpatient Hierarchical Condition Category (HCC) coding. This position will report to the Outpatient CDI Program Manager. This position focuses on improving the accuracy, quality, and completeness of clinical documentation in outpatient medical records while ensuring compliance with coding guidelines. The specialist will work collaboratively with providers, coding teams, and other healthcare professionals to facilitate accurate coding, improve risk capture, and optimize reimbursement while reflecting the true severity of illness and care provided.
Job Specifications:
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Registered Nurse (RN) with at least 3 or more years' experience either in the clinical field (RN), CDI field, or coding field required.
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1 or more years' experience in HCC/Risk Adjustment preferred.
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Minimum of 3 years of experience in clinical documentation improvement, outpatient Hierarchical Condition Category (HCC), or a combination of both preferred.
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Experience in an outpatient or acute care setting required.
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Ability to work independently, be resourceful, and possess strong organizational skills.
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Ability to communicate effectively with physicians and other clinical staff; be courteous and professional.
Required certifications/Licensure:
Active certification from one of the following preferred:
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AAPC (Certified Professional Coder - CPC, or Certified Documentation Expert - Outpatient CDEO)
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AHIMA (Certified Coding Specialist - CCS or Certified Documentation Improvement Practitioner - CDIP)
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ACDIS (Certified Clinical Documentation Specialist - CCDS or CCDS-O)
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Candidates without a certification must obtain one within the first year of employment.
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Proficiency in ICD-10-CM preferred.
Job Responsibilities:
Clinical Documentation Improvement: (50%)
Conduct concurrent and retrospective reviews of medical records to ensure clinical documentation captures the full scope of patient severity, risk of mortality and medical necessity for outpatient services. Collaborate with physicians, nurse practitioners, case managers and coder to identify opportunities for improving documentation of diagnoses, procedures and medical necessity. Query providers in a compliant and clear manner to address documentation gaps, ambiguities or discrepancies to support accurate coding and billing. Educate providers and clinical staff on best practices for documentation to improve encounter accuracy and quality.
Outpatient HCC coding: (25%)
Accurately assign ICD-10 CM for outpatient encounters, including clinical visits, emergency department visits, ambulatory surgeries, laboratory services and observation care. Abstract data and input into electronic medical record systems while adhering to organizational and regulatory coding standards. Ensure coding accuracy meets or exceeds a 95% accuracy rate, following official ICD-10-CM guidelines.
Data Integrity and Compliance (15%):
Maintain complete confidentiality of patient information and adhere to HIPAA regulations and organizational policies. Ensure documentation and coding practices meet compliance standards for regulatory and payer requirements.
Collaboration and Education (10%):
Act as a liaison between clinical providers and HIM to bridge the gap between documentation and coding requirements. Participate in education for providers on coding and documentation standards, focusing on outpatient services. Participate in ongoing education and stay current with changes in coding guidelines, CDI practices, and healthcare regulations.
Tidelands Health is an equal opportunity employer (EOE). Tidelands Health does not discriminate against employees or applicants for employment on the basis of race, color, creed, religion, age, national origin, disability, marital status, veteran status, gender, genetic information, familial status, or any other legally protected status.
