Clinical Documentation Improvement Specialist
HCA Healthcare, Campbell, California, us, 95011
Overview
Description: The CDI Specialist, Outpatient role focuses on modifying clinical documentation through concurrent interaction with providers and the healthcare team to promote compliant documentation capture of acute and chronic conditions. The CDI Specialist, Outpatient communicates clearly in virtual or face-to-face settings within physician practices and uses risk adjustment coding expertise to educate providers and staff, review documentation for improvement recommendations, and exceed customer expectations.
Job Summary and Qualifications Under direction of Coding Operations leadership, the CDI Specialist, Outpatient facilitates modifications to clinical documentation through concurrent interaction with providers and other members of the healthcare team. The CDI Specialist, Outpatient promotes compliant documentation capture of a patient’s acute and chronic conditions. Regular, clear, and consistent communication is expected to relay information on coding related topics in a virtual or face-to-face setting within physician practices. The CDI Specialist, Outpatient will utilize risk adjustment coding expertise to educate providers and staff, review documentation for improvement recommendations, and proactively seek to understand, meet, and exceed customer expectations.
Certification
Must hold at least one of the following credentials: Certified Risk Adjustment Coder (CRC®), Certified Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Professional Coder (CPC®), Certified Coding Specialist (CCS), Certified Coding Specialist Physician (CCS-P), RHIT (Registered Health Information Technician), RHIA (Registered Health Information Administrator)
Responsibilities
Reviews patient medical records to identify clinical documentation improvement opportunities for risk adjustment coding.
Provides coding and documentation improvement education to providers.
Utilize provider education strategies to promote complete and accurate clinical documentation and correct negative trends.
Identify patterns, trends, variances, and opportunities to improve documentation review processes.
Accurately capture detailed review results and educational efforts for performance measurement reporting.
Interact with appropriate resources that support professional growth and sustain continual learning.
Participate in CDI and risk adjustment coding continuing education to maintain certification.
Maintains a working knowledge of the coding guidelines/principles including: ICD-10-CM, CPT, HCPCS, and third party billing requirements.
Ensures compliance with coding policies and procedures.
Practices and adheres to the “Code of Conduct” philosophy and “Mission and Value Statement”.
Other duties as assigned.
Education
Bachelor’s Degree preferred
Experience
2+ years of risk adjustment coding experience in an outpatient setting.
Clinical documentation review experience to ensure familiarity with complex disease processes and broad clinical concepts.
Thorough knowledge of coding practices and official guidelines, Hierarchal Condition Category (HCC), ICD-10-CM, and CPT codes.
Requires proficiency in Microsoft applications, including Outlook, Word, Excel and PowerPoint.
About HCA Healthcare Physician Services Group is skilled in physician employment, practice and urgent care operations. We are experts in hospitalist integration and graduate medical education. We support HCA Healthcare’s commitment to the care and improvement of human life.
Benefits
Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
Free counseling services and resources for emotional, physical and financial wellbeing
401(k) Plan with a 100% match on 3% to 9% of pay
Employee Stock Purchase Plan with 10% off HCA Healthcare stock
Family support through fertility and family building benefits with Progyny and adoption assistance
Referral services for child, elder and pet care, home and auto repair, event planning and more
Consumer discounts through Abenity and Consumer Discounts
Retirement readiness, rollover assistance services and preferred banking partnerships
Education assistance (tuition, student loan, certification support, dependent scholarships)
Colleague recognition program
Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income
Note: Eligibility for benefits may vary by location.
Equal Opportunity We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
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Job Summary and Qualifications Under direction of Coding Operations leadership, the CDI Specialist, Outpatient facilitates modifications to clinical documentation through concurrent interaction with providers and other members of the healthcare team. The CDI Specialist, Outpatient promotes compliant documentation capture of a patient’s acute and chronic conditions. Regular, clear, and consistent communication is expected to relay information on coding related topics in a virtual or face-to-face setting within physician practices. The CDI Specialist, Outpatient will utilize risk adjustment coding expertise to educate providers and staff, review documentation for improvement recommendations, and proactively seek to understand, meet, and exceed customer expectations.
Certification
Must hold at least one of the following credentials: Certified Risk Adjustment Coder (CRC®), Certified Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Professional Coder (CPC®), Certified Coding Specialist (CCS), Certified Coding Specialist Physician (CCS-P), RHIT (Registered Health Information Technician), RHIA (Registered Health Information Administrator)
Responsibilities
Reviews patient medical records to identify clinical documentation improvement opportunities for risk adjustment coding.
Provides coding and documentation improvement education to providers.
Utilize provider education strategies to promote complete and accurate clinical documentation and correct negative trends.
Identify patterns, trends, variances, and opportunities to improve documentation review processes.
Accurately capture detailed review results and educational efforts for performance measurement reporting.
Interact with appropriate resources that support professional growth and sustain continual learning.
Participate in CDI and risk adjustment coding continuing education to maintain certification.
Maintains a working knowledge of the coding guidelines/principles including: ICD-10-CM, CPT, HCPCS, and third party billing requirements.
Ensures compliance with coding policies and procedures.
Practices and adheres to the “Code of Conduct” philosophy and “Mission and Value Statement”.
Other duties as assigned.
Education
Bachelor’s Degree preferred
Experience
2+ years of risk adjustment coding experience in an outpatient setting.
Clinical documentation review experience to ensure familiarity with complex disease processes and broad clinical concepts.
Thorough knowledge of coding practices and official guidelines, Hierarchal Condition Category (HCC), ICD-10-CM, and CPT codes.
Requires proficiency in Microsoft applications, including Outlook, Word, Excel and PowerPoint.
About HCA Healthcare Physician Services Group is skilled in physician employment, practice and urgent care operations. We are experts in hospitalist integration and graduate medical education. We support HCA Healthcare’s commitment to the care and improvement of human life.
Benefits
Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.
Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.
Free counseling services and resources for emotional, physical and financial wellbeing
401(k) Plan with a 100% match on 3% to 9% of pay
Employee Stock Purchase Plan with 10% off HCA Healthcare stock
Family support through fertility and family building benefits with Progyny and adoption assistance
Referral services for child, elder and pet care, home and auto repair, event planning and more
Consumer discounts through Abenity and Consumer Discounts
Retirement readiness, rollover assistance services and preferred banking partnerships
Education assistance (tuition, student loan, certification support, dependent scholarships)
Colleague recognition program
Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)
Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income
Note: Eligibility for benefits may vary by location.
Equal Opportunity We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
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