Clinical Documentation & Coding Excellence Lead

AbsoluteCARE Medical Center & Pharmacy; United States; On-site; USD 65,000 - 95,000; Full time

Job summary

AbsoluteCARE Medical Center & Pharmacy seeks a Clinical Documentation Excellence Specialist to improve ICD-10 coding accuracy and documentation quality across outpatient services. The role partners with physicians and care teams to ensure precise reflection of patient conditions and care provided.

The CDES will review records, raise EMR queries, and lead initiatives to elevate documentation standards while collaborating with leadership and clinical staff to implement best practices.

Qualifications

• 3+ years combined or equivalent experience as a clinical RN, CDI-certified, or outpatient coder with CDI certification.
• High School Diploma with relevant vocational training.
• Proven experience in Clinical Documentation Improvement.
• Ability to build trusted relationships with medical/behavioral health providers.
• Proficient in Microsoft Office and EMR usage.

Responsibilities

• Timely reviews of outpatient records to identify documentation or coding gaps.
• Collaborate with providers to refine documentation processes and accuracy.
• Engage with providers through EMR queries to clarify documentation needs.
• Lead initiatives to improve documentation and coding quality.
• Document clarification activities using EMR tools and address provider concerns.

Skills

Clinical RN experience

CDI certification

Outpatient coding experience

Relationship building with providers

Independent worker

Education

High School Diploma with vocational training

Tools

Microsoft Word

Excel

PowerPoint

Outlook

Electronic Medical Records (EMR)

Job description

AbsoluteCARE Medical Center & Pharmacy seeks a Clinical Documentation Excellence Specialist to improve ICD-10 coding accuracy and documentation quality across outpatient services. The role partners with physicians and care teams to ensure precise reflection of patient conditions and care provided.

The CDES will review records, raise EMR queries, and lead initiatives to elevate documentation standards while collaborating with leadership and clinical staff to implement best practices.