Clinical Documentation Specialist - Outpatient
R
ReveleerHealthcare Technology
United StatesFull-TimeMiddle
Salary85,000 - 120,000 USD per year
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Job Details
- Experience
- Minimum of 2 years outpatient CDI experience; 5 years of clinical experience
Requirements
- Graduate of an accredited nursing education program.
- Active and unrestricted Registered Nurse (RN) or Advanced Practice Provider (APP) license.
- Hold one of the following: Certified Documentation Expert-Outpatient (CDEO), Certified Clinical Documentation Specialist- Outpatient (CCDS-O), or Certified Documentation Improvement Practitioner (CDIP).
- Must hold Certified Risk Adjustment Coder (CRC) certification.
- Minimum of 2 years of outpatient CDI experience.
- 5 years of clinical experience.
- Proficiency in electronic medical records and technology enabling solutions.
- Experience navigating Epic, Athena, and Cerner EMRs.
- Strong understanding of CMS, HHS, Medicaid, and Rx HCC models.
- Knowledge of industry standards related to ICD-10-CM coding, AHA Coding Clinics, and Official Coding Guidelines.
Responsibilities
- Facilitate improvement in the overall quality and completeness of recapture and suspecting performance.
- Perform reviews of patient records to identify and validate Hierarchical Condition Category (HCC) diagnoses.
- Query providers to ensure accurate and complete documentation that supports HCC and condition-related diagnoses.
- Apply comprehensive knowledge of medical terminology, disease processes, and diagnostic tests to identify documentation gaps.
- Validate recapture and suspect conditions based on clinical evidence.
- Formulate recommendations to improve clinical logic and workflows.
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