Ambulatory Clin Doc Integrity Spec - CFH

Carle-Health; Champaign (IL); On-site; USD 36,000 - 60,000; Full time

Job summary

Carle Health seeks an Ambulatory Clinical Documentation Improvement (CDI) specialist to review diagnostic and E/M codes based on chart documentation. The role supports clinical care, teaches CPT E/M, CPT procedures, ICD10CM coding, and ensures compliance with regulatory requirements across the coding team and providers.

Responsibilities include education, audits, and remediation, with collaboration among HIM leadership.

Qualifications

• Certifications listed include CCS, RHIT, RHIA, CPCH, CPC, COC, CIC, CCS-P.
• AHIMA/AAPC credentials are required or strongly preferred.
• Detailed coding education and regulatory knowledge expected.

Responsibilities

• Review quality and completeness of diagnostic and E/M codes with emphasis on documentation.
• Apply medical terminology, anatomy, physiology, disease processes, treatments, diagnostics, meds and procedures to ensure proper code assignment.
• Adhere to coding practices, guidelines, conventions and hospital/policy requirements.
• Assist facility staff with documentation requirements to reflect care provided.
• Provide regular coding reviews and feedback on ICD10CM, CPT E/M or CPT Surgical coding.
• Provide education and education materials related to coding for team and providers.
• Follow query and notification process and escalate as needed.
• Provide statistics around changed/deleted codes to Manager/Director regularly.
• Escalate results to Compliance as required by audit policy/practice.

Education

CCS - AHIMA

RHIT - AHIMA

RHIA - AHIMA

CPCH - AAPC

CPC - AAPC

COC - AAPC

CIC - AAPC

CCS-P - AHIMA

Tools

CPT E/M coding

CPT Procedural Coding

ICD10CM coding

Job description

Overview

Performs ambulatory chart review to determine appropriate code assignment based on documentation in the chart to support clinical care provided, including preventives, Medicare Annual Wellness Visits, lowest and highest CPT E/M level, New Patient visits versus Consultation, and medical necessity. Assists in the provision of an efficient and effective clinical coding service within Carle by providing accurate and timely auditing and coding education to providers and coding team members to include CPT E/M coding, CPT Procedural Coding, and ICD10CM coding, as applicable. Ambulatory CDI work closely with HIM leadership and Compliance to assure Carle providers and coding team members are following all regulatory requirements for code assignment. Ambulatory CDI helps identify training needs through ongoing internal provider and staff audits and assists with remediation and reaudit post education. Ambulatory CDIs are responsible for producing coding education materials in formats such as Tips, power point or one to one sessions and group education sessions. Sends out notifications and queries to physicians in the EMR.

Qualifications

Certifications: Certified Coding Specialist (CCS) - American Health Information Management Association (AHIMA)American Health Information Management Association (AHIMA); Registered Health Information Technician (RHIT) - American Health Information Management Association(AHIMA)American Health Information Management Association(AHIMA); Registered Health Information Administrator (RHIA) - American Health Information Management Association(AHIMA)American Health Information Management Association(AHIMA); Certified Professional Coder - Hospital (CPCH) - American Academy of Professional Coders (AAPC)American Academy of Professional Coders (AAPC); Certified Professional Coder (CPC) - American Academy of Professional Coders (AAPC)American Academy of Professional Coders (AAPC); Certified Outpatient Coder (COC) - American Academy of Professional Coders (AAPC)American Academy of Professional Coders (AAPC); Certified Inpatient Coder (CIC) - American Academy of Professional Coders (AAPC)American Academy of Professional Coders (AAPC); Certified Coding Specialist - Physician-Based (CCS-P) - American Health Information Management Association (AHIMA)American Health Information Management Association (AHIMA), Education: , Work Experience:

Responsibilities

• Review quality and completeness of diagnostic and E/M codes with an emphasis on improving documentation.
• Apply comprehensive knowledge of medical terminology, anatomy and physiology, disease processes, treatment modalities, diagnostic tests, medications, and procedures to ensure proper code assignment.
• Adhere to accepted coding practices, guidelines, and conventions and any pertinent hospital or medical staff policies and guidelines.
• Assist facility staff with documentation requirements to completely and accurately reflect the patient care provided.
• Provide regular coding reviews and feedback to Carle medical staff and HIM coding team members specific to ICD10CM, CPT E/M or CPT Surgical coding.
• Provide education and education materials related to coding for the coding team members and providers.
• Follow query and notification process and escalates, as necessary.
• Provide statistics around changed and deleted codes to Manager/Director on a regular cadence.
• Escalate results to Compliance as required by audit policy/practice.
• Report compliance or other concerns directly to HIM Director/Vice President HIM as needed or indicated.

About Us

Find it here.

Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health.

Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois. We’ve grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We’re developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Methodist College. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet designations, the nation’s highest honor for nursing care. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: [e-mail].

Compensation and Benefits

The compensation range for this position is $26.03per hour - $43.47per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model.Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.