Nurse Clinical Documentation Specialist - Full-time / Part-time

POSITION SUMMARY
The CDS (Clinical Documentation Specialist) is responsible for reviewing medical records to evaluate overall completeness and quality of clinical documentation and to facilitate the accurate representation of the severity of illness and chronic conditions primarily for quality reporting and Medical Risk Adjustment (MRA). This involves extensive record review and interaction with physicians, nursing staff, Case Managers, Care Managers, data analytics staff, and coding staff. Active participation in Ambulatory team meetings and Payer meetings as they relate to Medical Risk Adjustment (MRA), the reporting of Hierarchical Condition Category (HCC) coding, and quality data reporting is required.
JOB QUALIFICATIONS
Education or Formal Training

• Graduate from a program of nursing, RN (Registered Nurse) preferred, but will also consider LPN (Licensed Practical Nurse) with experience.
• AAPC (American Academy of Professional Coders), AHIMA (American Health Information Management Association) or equivalent coding credential preferred or sufficient experience and training to qualify for AAPC or AHIMA coding credential

Special Qualifications (licensure, registration, etc.)

• Current state nursing license (RN or LPN)
• AAPC, AHIMA or equivalent coding credential or obtain credential within 6 months of employment required.

Knowledge, Skill and Ability

• Physician Clinic or Outpatient Clinic experience in a nursing field
• Knowledge of human anatomy, medical terminology, and Pathophysiology and Disease Process that allows for accurate diagnosis code abstraction from the medical record and querying of documenting providers for clarification
• Strong working knowledge of diagnosis coding using ICD10-CM (International Classification of Diseases Clinical Modification)
• Knowledgeable on CMS (Centers for Medicare and Medicaid Services) rules and regulations and ability to keep current.
• Ability to read and understand a variety of documents including EHR-based medical records (Electronic Health Record), Evaluation and Management documentation, operative reports and payer guidelines.
• Strong critical thinking, problem-solving, and deductive reasoning skills.
• Ability to learn and work with computer-based technologies and multiple software products.
• Keyboard proficiency
• Ability to communicate clearly and effectively, both verbally and in writing.
• Ability to comprehend and follow both oral and written instructions.
• Knowledge of HIPAA (Health Insurance Portability and Accountability Act) privacy and security compliance requirements

Experience

• Minimum 2 years recent clinical experience in medical setting
• Experience with diagnosis coding and documentation in a multi-specialty practice environment preferred

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Performs review process for all selected clinic patient records and visits to ensure documentation accurately reflects the severity of patienta??s illness and complies with coding and documentation guidelines.
• Performs review process for all selected clinic patient records and visits to ensure accurate assignment of ICD-10 codes to the highest degree of specificity possible both on claims and in the patienta??s problem list and past medical history.
• Develops documentation query protocol and educates essential staff on processes.
• Initiates assertive communication with physician or other care provider when documentation is unclear, using the most appropriate communication method a?? physician documentation request, face-to-face contact, phone call, etc.
• Tracks responses and trends compliance with documentation queries.
• Identifies trends in documentation and/or potential problems and develops action plans as needed.
• Works effectively with coding staff to clarify documentation issues on the back end.
• Provides information/education as necessary to physicians not responding to documentation requests.
• Reads and reviews coding guidelines, applicable professional bulletins and coding journals to maintain an up-to-date working knowledge of coding principles and specific Payer requirements.
• Attends in-services, appropriate continuing education seminars/webinars, and other meetings as required.
• Reviews records accurately and timely.
• Recognizes opportunities for documentation improvement.
• Formulates clinically credible documentation clarifications.
• Upholds guidelines set forth in the department/organization.
• Embraces and upholds philosophy of patient service and satisfaction.
• Employees are expected to comply with all regulatory requirements, including Joint Commission Standards.
• Is familiar with organization, department and job specific Environment of Care areas, including Life Safety, Utilities Management, Hazardous Materials Communications, Emergency Preparedness, Infection Control and Medical Equipment Failure.
• Adheres to Standard Precautions as appropriate, which may include:
• the use of protective barriers, as appropriate (e.g., gloves, masks, gowns, pocket masks, and/or safety glasses);
• handling and disposing of infectious waste appropriately; and
• hand washing as appropriate.

OTHER DUTIES/RESPONSIBILITIES
Performs other duties as assigned
MATERIALS AND EQUIPMENT DIRECTLY USED

• Computer
• Telephone/Voicemail
• Copy machine/fax machine
• Billing and Electronic Medical Records software products, MS Word, MS Excel.
• On-line Payer portals
• ICD10-CM
• Federal/State provider/insurance manuals (on-line)
• Managed Care provider/insurance manuals (on-line)

WORKING ENVIRONMENT/PHYSICAL ACTIVITIES

• Office environment with multiple interruptions by phone, email or in person
• Position requires long periods of sitting, data input/typing, computer usage, and phone
• Physically able to work hours defined by position
• Occasional evening or weekend work if needed
• Hearing and visual acuity sufficient for individual and group situations (with correction aids as needed)
• Some travel/driving to local clinics (all less than 25 miles) when needed

INTERRELATIONSHIPS

• Works closely with Director of Physician Revenue Cycle, Manager of Physician Billing, Physician Coding and Billing staff and employed providers (Physicians and Non-Physician Practitioners).
• Interacts with a wide variety of people, including clinic staff, clinic management, the compliance department, data analytics team, outside/independent contracted auditors, and government and managed care payer representatives.
• Reports to the Director of Physician Revenue Cycle.

SUPERVISORY DUTIES
None
PATIENT CARE/INTERACTION
When applicable, employees must be able to adjust the essential functions they perform appropriately to the age of their patient/customer. Employees must demonstrate knowledge of the principles of growth and development and the knowledge and skills necessary to provide for the primary population of patients served in the department. Employees demonstrate the ability to alter care and patient/family education based on the age or developmental level of the patient.
Primary patient population served. (Check all that apply)
____ Neonate/Infant (birth a?? 12 months) ____ Adult (18 a?? 69 years)
____ Child (13 months a?? 12 years) ____ Older Adult (70+ years)
____ Adolescent (13 a?? 17 years)
__x__ This position does not have regular patient contact.
EMPLOYEES ARE HELD ACCOUNTABLE FOR ALL DUTIES OF THIS JOB
A detailed list of all competencies is listed in the competency-based orientation checklist.