Clinical Documentation Advisor

Dartmouth-Hitchcock Health; Lebanon (NH); On-site; USD 70,000 - 90,000; Full time

Job summary

Dartmouth-Hitchcock Medical Center is seeking a regulatory coding specialist to perform coding audits and lead education on regulatory coding and documentation for providers and staff. The role includes developing annual education plans, coordinating and conducting coding education activities, and advising on charge capture tools in the electronic documentation system.

The candidate will apply CPT, ICD-10, and HCPCS guidelines across multiple departments, analyze data for trends, and ensure

Qualifications

• Associates degree in a related field or equivalent with 5 years recent coding experience required.
• Experience in a multi-specialty coding setting preferred.
• HCC Risk Coding background a plus.

Responsibilities

• Performs audit and education duties and acts as primary resource on regulatory coding and documentation rules.
• Develops the Annual Education Plan and coordinates coding education activities.
• Advises on charge capture tools in eD-H and on documentation tools development.
• Identifies trends through data analysis and policy reviews to ensure accurate revenue capture.
• Applies CPT, ICD-10, and HCPCS guidelines and E/M coding in documentation and auditing.
• Reports regulatory compliance activities to the Compliance Office quarterly.

Skills

Regulatory coding

Data analysis

Communication skills

Attention to detail

Policy interpretation

Education

Associate's degree in a related field

Tools

eD-H system

CPT/ICD-10/HCPCS coding

Job description

Overview

Assumes responsibility for regulatory coding and documentation audit and education activities with providers, clinical and ancillary staff.

Responsibilities

• Performs audit and education duties, acts as primary resource to clinical sections on regulatory coding and related documentation rules and regulation.
• Provides for numerous regulatory coding and documentation education aspects, including developing the Annual Education Plan and coordinating and coding education activities in assigned departments, ranging from routine record reviews to ongoing daily education activities, and conducting orientation for new provider staff.
• Acts as primary advisor on charge capture tools in eD-H, and regarding development of documentation tools in eD-H.
• Identifies trends through data analysis or chart review, reviewing existing policy for accuracy and developing new policies as necessary.
• Applies mandated regulatory, documentation and coding guidelines to documentation, including demonstrated proficiency with all areas of CPT, ICD-10 and HCPCS coding. E/M code assignment, auditing and education.
• Identifies key issues and is responsible for sharing pertinent information with the clinical sections and management to ensure accurate revenue capture and elevates regulatory concerns to management.
• Ensures regulatory compliance activities are reported to the Compliance Office on a quarterly basis.
• Performs other duties as required or assigned.

Qualifications

• Associates degree in a related field or equivalent with 5 years recent coding experience required.
• A background in a multi-specialty coding setting preferred.
• HCC Risk Coding background a plus.
• Strong organizational and analytical skills with the ability to effectively communicate (both orally and in writing) with all levels of staff.
• Attention to detail essential.

Required Licensure/Certifications

• Certified Professional Coder (CPC), Certified Professional Coder–Hospital (CPC-H) or Certified Coding Specialist – Physician Based (CCS-P) certification required.