Clinical Doc Improvement Speci

Cape Cod Healthcare Inc; Hyannis (MA); On-site; USD 70,000 - 100,000; Full time

Job summary

Cape Cod Healthcare is seeking a Clinical Documentation Improvement Specialist to review medical records and improve physician documentation to accurately reflect illness severity. The role involves risk adjustment reviews, coding verification, and education of clinical staff, with emphasis on collaboration with physicians and care teams.

Located in Hyannis, MA, this full-time position supports CAPABILITY OF CARES values while ensuring compliance with ICD-10-CM guidelines.

Qualifications

• Associate’s Degree in a relevant field preferred or combination of equivalent education and experience.
• Certified Professional Coder (CPC) certification required.
• Knowledge of clinical documentation guidelines and CDI program implementation experience preferred.
• Knowledge of ICD-10-CM, CPT codes, and disease processes.
• AHIMA/ACDIS CCDS/CDIP preferred but not required.

Responsibilities

• Review medical records to verify diagnosis codes are supported by documentation and ICD-10-CM guidelines.
• Assess whether diagnosis codes capture severity of illness and communicate with providers.
• Educate practice office physicians and staff on documentation needs and coding issues.
• Obtain clinical documentation through interaction with physicians and care teams.
• Generate accurate status reports for physicians and leadership.
• Perform other duties as assigned.

Skills

Organizational skills

Analytical skills

Writing skills

Interpersonal skills

Critical thinking

Problem solving

Education

Associate’s Degree in a relevant field

Certified Professional Coder (CPC) certification

CDIS or CDIP in active status with AHIMA or ACDIS (preferred)

Job description

Job Description

Clinical Documentation Improvement Specialist (261002-50025844)

Purpose of Position : The CDIS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians’ clinical documentation.

Description

• Conduct Risk Adjustment Reviews of medical records to verify whether diagnosis codes are supported by the documentation and ensure with ICD-10-CM Guidelines for Coding and Reporting.


• The diagnosis codes for each chronic or major medical condition have been captured correctly.


• Review for clinical indicators and query providers to capture the severity of illness of the patient.


• Conduct medical chart review to identifying opportunities for improving individual member risk adjustment score accuracy and communicate the same to the physician or his /her designee.


• Obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers.


• Educate practice office physicians and staff on clinical documentation needs, changes to clinical documentation guidelines and coding issues.


• Conduct follow up review of clinical documentation to ensure proper clinical information is documented in the patient’s record.


• Generate accurate and timely status reports for physicians & leadership.


• Performs other work related duties as assigned or requested.

Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects Cape Cod Healthcare’s commitment to CARES: compassion, accountability, respect, excellence and service.

Qualifications

• Associate’s Degree in a relevant field preferred or combination of equivalent education and experience.


• Knowledge of clinical documentation guidelines and CDI program implementation experience preferred.


• Certified Professional Coder (CPC) certification required.


• Knowledge of disease process, medical terminology, ICD-10-CM and CPT codes.


• Knowledge of ICD-10 principles and further documentation specificity highly preferred.


• CCDS or CDIP in an active status with AHIMA or ACDIS is preferred.


• Excellent organizational, analytical, writing and interpersonal skills.


• Dependable and self-directed.


• Critical thinking, problem solving and deductive reasoning skills.


• Proficient computer skills – familiarity with Windows based software programs.


• Knowledge of Medicare Part A and Part B.


• Knowledge of regulatory environment.


• Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers.


• Management/supervisory experience preferred.

Thepayrange displayed on each job posting reflects the anticipated range for new hires. A successful candidate’s actual compensation will be determined after taking factors into consideration such as the candidate’s work history, experience, skill set, and education. This is not inclusive of the value of Cape Cod Healthcare’s benefits package (if applicable), which includes among other benefits, healthcare/dental/vision and retirement. For annual salaries this is based on full-time employment.

Organization

Primary Location

Massachusetts-Hyannis

Department : HCI-PO - PHO

Hiring Pay Range : $ 0 - $ 0