Clinical Documentation Improvement Specialist

Community Health Services, Inc.; Hartford (CT); On-site; USD 76,000 - 113,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

401(k) Plan with employer match

Generous Paid Time Off

9 Paid Holidays

Competitive Pay

Employer Paid Disability Insurance

Employee Assistance Programs

Worker's Compensation

Job summary

Community Health Services, Inc. in Hartford, CT is seeking a Clinical Documentation Improvement Specialist (CDIS) for a full-time, exempt position in the Quality Department.

The role reports to the Chief Quality Officer and focuses on chart review, CMS coding guidance, and population health improvement. Requirements include a Bachelor’s Degree in Nursing or related field, 3 years in quality improvement or health information management, and strong ICD-10/DRG knowledge plus proficiency with the

Qualifications

• Bachelor’s Degree in Nursing or a related field.
• Three years of experience in quality improvement or health information management.
• Deep knowledge of clinical conditions, procedures, and documentation requirements.
• Strong understanding of ICD-10, DRG, and related classification systems.
• Advanced proficiency with Microsoft Office Suite products and ability to navigate an Electronic Health Record.

Responsibilities

• Audit and analyze clinical documentation in the electronic health record to ensure documentation is clear, accurate, reflects the severity of the clinical presentation and is consistent with CMS coding guidelines.
• Collect, analyze, and interpret health data to identify trends, risks, and opportunities for improvement. Use health metrics and analytics to monitor the health status of populations and track progress toward health goals.
• Serves as an organizational subject matter expert on outpatient coding and acceptable documentation practices. Plan and conduct training for clinical stakeholders that include goals, objectives, and lesson plans related to electronic health record, current ICD and CPT coding.
• Maintain knowledge of ICD and CPT coding and clinical documentation requirements and recommended practices.
• Identifies areas for improvement in documentation.
• Conducts meetings with providers and other clinical staff to review documentation issues and improvement opportunities.
• In collaboration with providers, recommend and/or oversee adjustments in documentation to ensure compliance, accuracy, and appropriate reimbursement, including for clinical quality measures such as UDS and HEDIS.
• In collaboration with other members of the quality team, the CDIS uses clinical documentation improvement to design, implement, and manage strategies that improve the overall health and well-being of the CHS' patient population.
• Data collection and reporting for incentive programs and grants.
• Act as a liaison between clinical teams, the IT team, and Medical Records in the development and enhancement of clinical documentation systems
• Maintain required training for competency of HIPAA and Compliance, Infection Control, and other topics as assigned.Collaborates with CQO and other organizational leaders to develop ongoing documentation training for clinical staff.
• Participate in quality and process improvement efforts in the department and the organization as requested or as directed

Skills

ICD-10 knowledge

DRG knowledge

EHR navigation

MS Office proficiency

Education

Bachelor's Degree in Nursing or related field

Tools

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

Microsoft Access

Job description

Clinical Documentation Improvement Specialist

Exempt, Full-Time Position

Annual Salary: $75,504.00 - $112,632.00 per year

Since 1970, Community Health Services has existed to provide comprehensive health care services to the residents of Hartford and Windsor. We were made for the community, by the community, to offer a full spectrum of services to include medical, behavioral health care, dental care, a full-service pharmacy and more. Our goal is to offer our patients a medical home; a place where they can come for all of their needs; a place where the clinical staff know them by their first name. Our dedicated staff demonstrate the good we can do on a daily basis when we provide quality care with dignity to each and every individual. We want to help our patients get all of the health care they need - when they need it - so they may too live a healthier and happier life.

Community Health Services, Inc. is seeking experienced an experienced Clinical Documentation Specialist for a full time, 40-hour opportunity in our Quality Department. Reporting to the Chief Quality Officer, the Clinical Documentation Specialist is an integral part of the care team, providing top-quality assistance to patients and contributing to the efficiency and effectiveness of individual patient visits as well as to improved population health.

The successful candidate will have:

• A Bachelor’s Degree in Nursing or a related field
• Three (3) years of experience in quality improvement or health information management
• Deep knowledge of clinical conditions, procedures, and basic documentation requirements
• Strong understanding of, and demonstrated experience using ICD-10, DRG, and other related classification systems
• Advanced proficiency with Microsoft Office Suite products (Word, Excel, PowerPoint, Access) and ability to navigate an Electronic Health Record

Essential Functions:

• Audit and analyze clinical documentation in the electronic health record to ensure documentation is clear, accurate, reflects the severity of the clinical presentation and is consistent with CMS coding guidelines
• Collect, analyze, and interpret health data to identify trends, risks, and opportunities for improvement. Use health metrics and analytics to monitor the health status of populations and track progress toward health goals
• Serves as an organizational subject matter expert on outpatient coding and acceptable documentation practices. Plan and conduct training for clinical stakeholders that include goals, objectives, and lesson plans related to electronic health record, current ICD and CPT coding.
• Maintain knowledge of ICD and CPT coding and clinical documentation requirements and recommended practices.
• Identifies areas for improvement in documentation
• Conducts meetings with providers and other clinical staff to review documentation issues and improvement opportunities
• In collaboration with providers, recommend and/or oversee adjustments in documentation to ensure compliance, accuracy, and appropriate reimbursement, including for clinical quality measures such as Uniform Data Systems (UDS) and Healthcare Effectiveness Data and Information Set (HEDIS).
• In collaboration with other members of the quality team, the CDIS uses clinical documentation improvement to design, implement, and manage strategies that improve the overall health and well-being of the CHS' patient population.
• Data collection and reporting for incentive programs and grants
• Act as a liaison between clinical teams, the IT team, and Medical Records in the development and enhancement of clinical documentation systems
• Maintain required training for competency of HIPAA and Compliance, Infection Control, and other topics as assigned.Collaborates with CQO and other organizational leaders to develop ongoing documentation training for clinical staff.
• Participate in quality and process improvement efforts in the department and the organization as requested or as directed

All candidates for employment at CHS must successfully pass a pre-employment background check and drug screen.

Some benefit programs available to eligible employees include:

• Medical Insurance
• Dental Insurance
• Vision Insurance
• 401(k) Plan and up to 4% Employer Match
• Generous Paid Time Off
• 9 Paid Holidays
• Competitive Pay
• Employer Paid Life Insurance
• Employer Paid Short Term Disability
• Employer Paid Long Term Disability
• Employee Assistance Programs
• Worker's Compensation
• Various Leave Programs - Bereavement, Military, Maternity, and more

Community Health Services is An Equal Opportunity/Affirmative Action Employer.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status, age or any other federally protected class.