Clinical Documentation Specialist: HCC & Risk Adjustment

University Hospitals Pain Management; Cleveland, Northern (OH, KY); Hybrid; 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

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