Clinical Documentation Improvement Specialist I

SCP Health; United States; Remote; USD 46,000 - 66,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

401(k) with company match

Paid Time Off

Holidays

Professional Development Support

Wellness Resources

Job summary

SCP Health is hiring for a Documentation Improvement Specialist who educates clinicians on CMS documentation guidelines and coding requirements. You will analyze charts, counsel outliers, and provide training across mySCP Care tools. Expect travel to client sites and collaboration with analytic teams.

The role requires a Bachelor’s degree with HIM or nursing background, plus 2 years in hospital or physician practice settings. Remote/hybrid work options may be available.

Qualifications

• Bachelor's degree required.
• Health Information Management, Nursing, or related field preferred.
• 2 years’ experience in hospital or physician practice environment.
• Experience with EMR documentation and coding guidelines.

Responsibilities

• Advise and educate on documentation/coding for 5–10 contracts.
• Counsel clinicians on outliers monthly or as directed.
• Perform chart analysis to support CMS guidelines and RVU improvements.
• Onboard and train clinicians on SCP tools and portals.
• Travel to territories for in-person education and training.
• Support clinician onboarding and training sessions.
• Analyze coding and billing data to identify documentation improvements.
• Collaborate with Data and Performance Analytics on clinician feedback.

Skills

EMR knowledge

MS Office

CMS documentation guidelines

Learning new systems

Education

Bachelor's degree

Health Information Management

Nursing

Other related field

Tools

Cerner

EPIC

Medhost

Meditech

Job description

At SCP Health, what you do matters

As part of the SCP Health team, you have an opportunity to make a difference. At our core, we work to bring hospitals and healers together in the pursuit of clinical effectiveness. With a portfolio of over 8 million patients, 7500 providers, 30 states, and 400 healthcare facilities, SCP Health is a leader in clinical practice management spanning the entire continuum of care, including emergency medicine, hospital medicine, wellness, telemedicine, intensive care, and ambulatory care.

Why you will love working here:

• Strong track record of providing excellent work/life balance.
• Comprehensive benefits package and competitive compensation.
• Commitment to fostering an inclusive culture of belonging and empowerment through our core values - collaboration, courage, agility, and respect.

JOB DESCRIPTION:

Primary Duties and Responsibilities:

• To advise and educate Emergency Medicine, Hospital Medicine, Critical Care Medicine, Telemedicine, and Urgent Care internal and external clients (clinicians/facility/operations) on current documentation/coding requirements via phone, webinar, and/or in person for a portfolio of 5-10 contracts.
• To counsel clinicians identified as outliers via face-to-face interaction, phone, web-based, and/or email, on a minimum of a monthly basis or as coordinated by Director of Documentation Assurance.
• To perform chart analysis/recommendations to support quality documentation feedback to clinicians as it relates to CMS Guidelines, Attestations, Procedures, and internal Queries.
• Educate and counsel clinicians on how to resolve external chart queries.
• Travel to territories as required to provide in-person documentation education, oversight, feedback, and training with EMR training as needed.
• Participate in clinician Electronic Medical Record (EMR) training and provide feedback/clarification on documentation/coding and workflow concepts.
• Analyze coding and billing data to identify documentation and RVU outliers at the facility and clinician level to deliver additional documentation/coding education.
• Assist clinicians and chart acquisition team with chart flow process issues.
• Onboard and train all new clinicians on mySCP Care/mySCP Complete and the provider portal and act as a first line of contact for mySCP Care/mySCP Complete related issues and questions from clinicians and operations.
• Educate and give feedback to all new clinicians on documentation performance within the first month of service.
• Provides support to CDIS II other and/or senior CDIS as needed on major client and department initiatives. Understands the department’s strategic plans and performance measures required to support that plan. Continues to seek out tasks and other initiatives that provides the opportunity for growth and development in the CDIS field.
• Participate in standing clinician meetings to highlight documentation, coding, and quality initiatives.
• To participate in company-wide initiatives related to clinical documentation as identified by Clinical Leadership
• Collaborate with Data and Performance Analytics Team on clinician feedback. Conduct audits regarding clinician RVU and productivity as requested.
• Present Clinician Onboarding WebEx presentations bi-weekly and provide additional sessions as needed (HM)
• Create and distribute Monthly Facility Report Cards and trending reports to Medical Directors and Operations (HM)

Knowledge, Skills, and Abilities:

• Maintain knowledge of EMR’s, i.e., Allscripts, Cerner, CPSI, EPIC, McKesson, Paragon, Medhost, Meditech
• Basic knowledge in Microsoft office suite
• Experience in clinician CMS documentation guidelines
• Ability to learn additional reporting avenues and systems

EDUCATION (Required and/or Preferred):

• Bachelor’s degree - required
• Health Information Management
• Nursing
• Another related field

FIELD OF STUDY (Preferred):

• Health Information Management (HIM), Nursing, Other healthcare related field

SUPERVISION EXERCISED:

• None

QUALIFICATIONS:

Previous Experience:

• 2 years’ experience in Hospital or Physician practice environment performing related job duties as described above.
• Experience with Emergency Medicine, Hospital Medicine, Urgent Care documentation and coding guidelines preferred.
• Experience with one or more following EMR’s: Cerner, EPIC, Medhost, or Meditech
• Strong skills in Microsoft Suite such as Outlook, Excel, and PowerPoint.
• Microsoft Excel functions include, but not limited to: Data Entry, Data Filters, Data Sorting, Pivot Tables, Charts, Formatting, and Lookup Functions
• Microsoft PowerPoint functions to include, but not limited to: Design, Layout, Animation, Formatting, Customization, Timing, Recording.

Certification and Licenses:

• Registered Health Information Administration (RHIA), Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Professional Coder (CPC), or Certified Coding Specialist (CCS) and prior intermediate coding experience

CONTACTS INSIDE AND OUTSIDE THE ORGANIZATION:

• Internal Department - feedback and education, auditing
• External Department - feedback, education, auditing, communicating errors
• External Customer Facing - clinician education and feedback regarding chart completion
• Identify trends and problem resolution in clinician documentation/coding impacting billing, RVU, and Coding assignment
• Communication on clinician documentation issues identified with HIM, IT, Clinicians including Med Director, and SCP Operators.
• Communication on chart flow issues, errors, and resolution identified internally and externally

WORK ENVIRONMENT AND PHYSICAL DEMANDS:

• Works independently at a Clients Site / Hospital facility
• Professional setting
• Continuous sitting
• Continuous oral & written communication and listening skills
• Continuous computer use
• Occasional bending, kneeling, lifting, pulling & pushing up to 10 pounds
• Job requires a high level of mental awareness
• PRIMARY LOCATION: Home Based or office location Lafayette, LA, Dallas, TX, or Atlanta, GA (if within 30 miles of office location)
• Travel to territories as required to provide in-person documentation education, EMR training as needed with EMR team, or CDIS II.

CONFIDENTIALITY:

The daily activities of this position will be held in the strictest confidence whether it is in regard to a person, individual and/or a strategic initiative. Confidentiality must be maintained on any and all documents and/or information processed.

COMPLIANCE:

All SCP Health employees will abide by all policies and procedures including the SCP Health Corporate Compliance Program and will adhere to all applicable local, state, and federal laws.

DISCLAIMER:

The above statements reflect the general duties considered necessary to describe the essential functions of the job as identified and shall not be considered as a detailed description of all work requirements which may be inherent in the position. They may be subject to change at any time due to reasonable accommodations or other reasons.

Pay Range:

46,163.00 - 65,601.00 USD annually

This range represents the anticipated base salary for this role. Actual compensation will be determined based on experience, qualifications, and internal equity considerations.

We offer a comprehensive benefits package designed to support your health, financial well-being, and work-life balance, including medical dental, vision insurance, a 401(k) plan with a company match, paid time off and holidays, professional development support, and employee wellness resources.

Visit our website for further information.https://myscpbenefits.com/

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