Ambulatory Clinical Documentation Specialist - Remote

Altru Health System; Grand Forks (ND); On-site; USD 74,000 - 111,000; Full time

Job summary

Altru Health System in Grand Forks, ND is seeking an Ambulatory Clinical Documentation Specialist to enhance accuracy of clinical documentation reflecting patient complexity and appropriate E/M levels. The CDS serves as advisor to providers and collaborates with CDI teams to improve documentation and reimbursement.

Responsibilities include pre-visit and post-claim chart reviews, education to providers, identifying opportunities to clarify medical records, and keeping up to date with CMS

Responsibilities

• Identifies opportunities to recapture previously documented HCC conditions and identify potential new or “suspect” conditions supported by appropriate clinical indicators and the patient’s medical record.
• Evaluates E/M encounters to identify opportunities related to medical decision-making, patient acuity, E/M level assignment, diagnosis capture, and HCC documentation.
• Delivers individualized and group education to providers based on findings from pre-visit and post-claim reviews, data analytics, provider performance trends, and identified documentation or coding opportunities.
• Collaborates with Professional Fee CDI leadership, CDI and coding teams, and other organizational partners to support program objectives, coordinate initiatives, and foster effective teamwork.
• Uses performance, outcome, and other available data to identify high-priority providers, specialties, encounter types, workflow opportunities, and educational needs.
• Supports the development, implementation, and evaluation of Professional Fee CDI workflows, processes, education schedules, and program initiatives.
• Identifies opportunities to clarify the medical record in a compliant and non-leading manner, consistent with applicable coding, documentation, query, regulatory, and organizational guidelines.
• Creates and delivers specialty-specific education and ongoing feedback based on chart review findings, data analytics, provider performance trends, and identified documentation or coding opportunities.
• Communicates effectively with providers, CDI team members, coding, compliance, and other stakeholders through individual consultations, provider meetings, department or specialty sessions, and other appropriate forums.
• Maintains current knowledge of CMS requirements, official coding guidelines, HCC models, risk adjustment principles, E/M guidelines, clinical documentation requirements, and applicable industry standards.

Job description

Altru Health System in Grand Forks, ND is seeking an Ambulatory Clinical Documentation Specialist to enhance accuracy of clinical documentation reflecting patient complexity and appropriate E/M levels. The CDS serves as advisor to providers and collaborates with CDI teams to improve documentation and reimbursement.

Responsibilities include pre-visit and post-claim chart reviews, education to providers, identifying opportunities to clarify medical records, and keeping up to date with CMS