Outpatient Clinical Documentation Specialist

About the Role

The Outpatient Clinical Documentation Specialist (CDS) plays a crucial role in ensuring the quality and completeness of medical record documentation for outpatient encounters. This includes clinic visits, outpatient surgeries, emergency department visits, and other ancillary services. You will collaborate with physicians, coders, and clinical staff, using your expertise in documentation and coding to achieve improved documentation results for the organization.

Your responsibilities will involve evaluating the medical record concurrently, prospectively, and retrospectively. You will communicate with physicians and other clinicians to ensure documentation accurately reflects the patient's clinical picture, severity of illness, and complexity. This accurate and complete documentation is vital for coding, profiling, and outcomes reporting for both the facility and physicians.

Key Responsibilities

• Utilize knowledge of national coding guidelines (ICD-10 and CPT), Hierarchical Condition Categories (HCC), standards of compliance, and clinical knowledge.
• Identify opportunities to improve documentation and achieve desired results.
• Work independently, be resourceful, and possess strong organizational skills.
• Communicate effectively with physicians and other clinical staff, demonstrating courtesy, tact, and cooperation.
• Apply critical thinking and sound judgment throughout all phases of your work.

Education and Experience Required

• CCDS, CDIP, RHIA, RHIT, CPC, CRC, or CCS certification (or a combination thereof) is preferred. Must obtain CRC within one year of hire.
• Three (3) or more years of experience in a clinical field (RN), CDI field, or coding.
• One (1) or more years of experience in HCC/Risk Adjustment is preferred.
• Knowledge of ICD-10 and HCC coding guidelines.
• Exemplary organizational and communication skills.
• Ability to build relationships, negotiate processes and outcomes, and influence behaviors.
• Knowledge of healthcare fiscal management goals and strategies, including reimbursement, coding guidelines, and case management.
• Familiarity with electronic medical record systems and demonstrated Microsoft Office competency.
• Ability to handle pressure, meet deadlines, and manage work with variable requirements.

Certifications and Licensures Required

• CCDS, CDIP, RHIA, RHIT, CPC, CRC, or CCS certifications preferred. Must obtain CRC within one year of hire.
• Clinical Documentation Specialist certification (CCDS-O or CDEO) strongly encouraged.

Additional Information

• Department: Outpatient CDIS
• Shift: Day Job

Key skills/competency

• Clinical Documentation Improvement (CDI)
• Medical Record Documentation
• Outpatient Coding
• ICD-10
• CPT Codes
• HCC Coding
• Risk Adjustment
• Medical Auditing
• Healthcare Compliance
• Physician Communication