Clinical Documentation Specialist (CDI), Pro Fee

University Hospitals Pain Management; Cleveland, Northern (OH, KY); On-site; USD 70,000 - 90,000; Full time

Job summary

University Hospitals Pain Management is seeking a Professional Fee Clinical Documentation Specialist to improve documentation quality for accurate risk adjustment and appropriate E/M levels. The role emphasizes pre-visit and post-claim reviews, education to providers, and collaboration with the CDI team to optimize patient care documentation.

The CDS focuses on identifying chronic conditions reflected in HCCs, ensuring proper documentation, and maintaining current CMS guidance while safeguarding

Qualifications

• The CDS reviews documentation and identifies opportunities to capture HCC diagnoses.
• Holds HIPAA compliance and stays current on CMS guidelines.

Responsibilities

• Coordination with Professional Fee CDI Program leadership and colleagues. Fosters teamwork and builds strong team relationships.
• Performs pre-visit chart reviews to highlight relevant documentation and diagnoses, identifying new HCC opportunities and supporting appropriate E/M levels.
• Uses performance data from third-party sources to identify high priority providers and opportunities for improvement.
• Creates specialty-specific education from data analytics and clinical reviews for post-claim education.
• Develops and maintains an education schedule for hospital and clinic providers on documentation, codes, and E/M level updates.
• Delivers ongoing feedback to emphasize complete documentation during clinic meetings and individual sessions.
• Maintains knowledge of CMS guidelines, understanding HCC implications for documentation and risk adjustment.
• Maintains confidentiality of patient, employee, and physician information per HIPAA guidelines.
• Seeks growth opportunities, attends meetings and trainings, and pursues certifications as required.
• Communicates with patients and staff with tact, and serves on department/institution committees as requested.
• Performs other duties as assigned and adheres to all policies and PHI safeguards.

Job description

A Brief Overview

The Professional Fee Clinical Documentation Specialist (CDS) will serve as an advisor and expert resource for providers to improve the accuracy of clinical documentation to support patient complexity, risk profiles and appropriate E/M levels thereby supporting the provider's efforts and their professional fee billing. The CDS primarily assist providers in identifying clinically relevant information and capturing the clinical documentation needed to accurately reflect patient acuity. The Professional Fee CDS will focus on the recapture and identification of chronic conditions reflected in Hierarchical Condition Categories (HCCs), which directly impact the patient risk adjusted profile (RAF score) calculated by the associated risk plans. They will also assist with highlighting opportunities based on the provider's medical decision making to appropriately reflect the level of service provided for patient care.The Professional Fee CDS will be responsible for completing pre-visit and post-claim reviews as well as providing clear communication and education to providers on their documentation, coding and billing practices, in adherence to compliance standards set by governing entities such as CMS, AHA, etc Pre-visit reviews are intended to identify documentation opportunities for the provider to recapture previously documented HCCs diagnoses, or new suspect conditions not previously captured that are identified by the CDS's comprehensive chart reviews. These efforts assist in establishing accurate risk profiles and related health care costs Post-claim reviews focus on E/M encounters and highlight opportunities based on a provider's medical decision making and the patient's acuity to support appropriate and accurate E/M level assignments as well as any HCCs identified The Professional Fee CDS will also coordinate with colleagues from the CDI Program or other members of the organization regarding education and training geared towards improving clinical documentation based on findings from pre-visit and post-claim reviews

What You Will Do

• Coordination with Professional Fee CDI Program leadership and colleagues. Fosters teamwork and utilizes strong team building measures
• Performs pre-visit chart reviews to assist in highlighting relevant documentation and diagnoses in compliance with governing policies and industry guidelines. Applies a “clinical detective” mindset to identify new HCC diagnosis capture opportunities based on appropriate clinical indicators for the patient. Also performs post-claim reviews focused on appropriate E/M level assignments and any opportunities related to level of service and HCCs.
• Uses performance and outcome data from third-party support or other sources to identify high priority providers
• Creates specialty-specific education on relevant topics as identified in data analytics and from clinical encounter reviews and post-claim education chart reviews
• Develops and maintains a systematic education schedule and approach for providers in the hospital and clinic/office setting including but not limited to complete documentation, appropriate diagnosis code selection, E/M level assignments and updates to coding guidelines.
• Delivers ongoing feedback and education to communicate importance of complete documentation and key concepts during regular clinic or provider meetings or on individual basis, as needed
• Upholds working knowledge and stays current on latest CMS and industry guidelines, with specific understanding of HCCs and implications for documentation
• Maintains strict confidentiality of all patients, employee and physician information according to HIPAA guidelines

Additional Responsibilities

Shares in organization’s vision, demonstrates its values, supports its philosophy and is sensitive to its mission. Demonstrates knowledge of and follows departmental and hospital policies and physician office procedures

• Seeks out opportunities for individual growth and development, including attending various meetings, conferences, courses, seeking certifications, as required.
• Uses tact and sensitivity when communicating with patients, visitors, co-workers, and other personnel
• Serves on department and/or institutional committees as requested
• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.