Ambulatory Clinical Documentation Improvement Specialist

Catholic Health; Buffalo (NY); Hybrid; USD 90,000 - 110,000; Full time

Job summary

Catholic Health seeks an Ambulatory Clinical Documentation Improvement Specialist to assist providers in capturing accurate documentation for appropriate E/M levels and HCCs, supporting revenue capture and compliance.

The role focuses on pre-visit chart reviews, provider onboarding, audits, and education within a multi-facility health system. Travel to various facilities is required.

Qualifications

• Bachelor's Degree or over five years of related healthcare experience in lieu of degree.
• One of the following Coding credentials is required: CCS-P, CPC, CRC, or other coding credential.
• Strong preference for RN or LPN credential.

Responsibilities

• Assist providers in capturing clinical documentation to reflect patient acuity and appropriate E/M level for billing.
• Onboard new providers and explain CDI activities of the Health System; perform routine audits of documentation to support diagnoses and E/M assignments.
• Identify documentation opportunities and capture or identify chronic conditions reflected in HCCs; coordinate with Provider Liaisons and Ambulatory CDI Program education.

Skills

Clinical documentation

E/M coding

ICD-10 CM

EPIC

Communication

Project management

Interpersonal skills

Analytical thinking

Education

Bachelor's Degree

Coding credentials CCS-P CPC CRC

RN/LPN preferred

Tools

EPIC

Excel

PowerPoint

Job description

Facility: Administrative Regional Training Cntr

Shift: Shift 1

Status: Full Time FTE: 1.000000

Bargaining Unit: ACE Associates

Exempt from Overtime: Exempt: Yes

Work Schedule: Days

Hours: 7-3 or 8-4

Summary:

The Ambulatory Clinical Documentation Improvement Specialist (CDS) will assist providers in capturing the clinical documentation needed to accurately reflect patient acuity and support the appropriate diagnosis and E/M level for professional fee billing. The Ambulatory CDS will focus on two primary tasks, the appropriate documentation and assignment of diagnoses and E/M levels and the capture or identification of chronic conditions reflected in Hierarchical Condition Categories (HCCs).

Appropriate and accurate ICD-10 CM diagnosis assignment and sequencing as well as appropriate E/M level assignment is important for both revenue capture and compliance. For this task, this position will be responsible for onboarding new providers, explaining the audit and CDI activities of the Health System, and performing routine audits of a provider's documentation to support his/her diagnosis capture and sequencing and E/M assignment for the visit. These audits and any education provided will be tracked and reported to Physician Enterprise leadership.

HCCs directly impact the patient risk adjusted profile (RAF score) calculated by the associated risk-adjusted plans. For this part of the role, the Ambulatory CDS will be responsible for completing pre-visit chart views for scheduled patients. Pre-visit reviews are intended to identify documentation opportunities for the provider to recapture previously documented HCCs diagnoses or new HCCs not previously captured that are identified by reviewing past medical records. The Ambulatory CDS will coordinate with Provider Liaisons and other colleagues from the Ambulatory CDI Program on education and training geared toward improving clinical documentation. This position supports a multi-facility / multi-location health system, and as such, requires the ability to travel to various Catholic Health facilities throughout the Health System.

Responsibilities

EDUCATION

• Bachelor's Degree or over five (5) years of related healthcare experience in lieu of degree
• One of the following Coding credentials is required: CCS-P, CPC, CRC, or other coding credential
• Strong preference will be given to candidates who have an RN or LPN credential

Experience

• Extensive clinical knowledge and understanding of pathophysiology demonstrated by at least five (5) years of experience in E/M coding or nursing

KNOWLEDGE, SKILL, AND ABILITY

• Strong critical thinking skills and utilization of clinical knowledge to identify potential clinical indicators supporting patient acuity and clarification of the medical record
• Excellent written and verbal communication skills
• Possesses strong project management skills
• Possesses strong interpersonal skills, with demonstrated success at communicating effectively with all levels of the organization
• Ability to work independently in a time-oriented environment
• Demonstrates skilled ability and comfort with electronic medical records (EPIC preferred)
• Proficient with personal computer applications (Excel, Word and Power Point)
• Ability to build education material that is meaningful for providers and team members
• Strong problem solving and investigative skills

WORKING CONDITIONS

• Works in office setting and remotely with computer and medical records
• Sits for prolonged periods of time, in front of a computer screen
• Normal heat, light space, and safe working environment; typical of most office jobs
• After satisfactorily completing a probationary period, this position may be eligible for remote work on days when no travel to an office location is needed, pursuant to CHS remote working policies

ENVIRONMENT

• Normal heat, light space, and safe working environment; typical of most office jobs
• Occasional exposure to one or more mildly unpleasant physical conditions