Clinical Documentation & Coding Specialist (HCC Focus)

Santa Barbara Cottage Hospital; United States; Remote; USD 66,000 - 99,000; Full time

Job summary

Mount Sinai Health System seeks a Clinical Documentation Specialist to support improvements in ambulatory documentation and coding. The role collaborates with physicians, Health Information Management, and Mount Sinai Health Partners to review and code ambulatory records, educate physicians, and liaise with the coding department.

This position focuses on improving HCC coding accuracy and leveraging billing data to enhance documentation quality across primary care outpatient encounters.

Qualifications

• 3+ years of coding experience in a healthcare setting, preferably outpatient.
• Experience with HCC risk adjustment coding and data validation.
• Strong knowledge of ICD-10, CPT, and HCPCS coding systems.

Responsibilities

• Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation and coding.
• Reviews charts to assess the clinical status and identify documentation gaps for outpatient encounters, especially primary care.
• Performs coding and clinical validation audits with emphasis on HCC coding.
• Leverages IT data to improve outpatient coding completeness and specificity.
• Communicates chart reviews with physician office staff and distributes related correspondence.
• Assesses CDQI alerts for accuracy and completeness.
• Reviews outpatient visit diagnoses and service levels prior to claim submission.
• Solicits clarification from physicians to ensure complete documentation.
• Participates in data acquisition and reporting to clinicians and leadership.
• Interacts with physicians to educate on compliant documentation and coding; acts as clinical liaison to coding department.
• Identifies training needs and conducts coaching for clinicians and staff.
• Monitors coding changes by government payers; educates on coding and compliance.
• Ensures documentation remains compliant with state and federal regulations.
• Performs other related duties.

Skills

HCC Risk Adjustment experience

3+ years coding experience

Clinical documentation

Outpatient coding

Education & mentoring

ICD-10 knowledge

CPT/HCPCS knowledge

APC coding

Data interpretation

Front-end process improvement

Communication skills

Time management

Attention to accuracy

Education

High school diploma or GED

Associates degree or higher preferred

Tools

Microsoft Excel

Job description

Mount Sinai Health System seeks a Clinical Documentation Specialist to support improvements in ambulatory documentation and coding. The role collaborates with physicians, Health Information Management, and Mount Sinai Health Partners to review and code ambulatory records, educate physicians, and liaise with the coding department.

This position focuses on improving HCC coding accuracy and leveraging billing data to enhance documentation quality across primary care outpatient encounters.