Professional Clinical Documentation Specialist

Altru Health System; Grand Forks (ND); On-site; USD 74,000 - 111,000; Full time

Job summary

Altru Health System in Grand Forks, ND is seeking an Ambulatory Clinical Documentation Specialist to enhance accuracy of clinical documentation reflecting patient complexity and appropriate E/M levels. The CDS serves as advisor to providers and collaborates with CDI teams to improve documentation and reimbursement.

Responsibilities include pre-visit and post-claim chart reviews, education to providers, identifying opportunities to clarify medical records, and keeping up to date with CMS

Responsibilities

• Identifies opportunities to recapture previously documented HCC conditions and identify potential new or “suspect” conditions supported by appropriate clinical indicators and the patient’s medical record.
• Evaluates E/M encounters to identify opportunities related to medical decision-making, patient acuity, E/M level assignment, diagnosis capture, and HCC documentation.
• Delivers individualized and group education to providers based on findings from pre-visit and post-claim reviews, data analytics, provider performance trends, and identified documentation or coding opportunities.
• Collaborates with Professional Fee CDI leadership, CDI and coding teams, and other organizational partners to support program objectives, coordinate initiatives, and foster effective teamwork.
• Uses performance, outcome, and other available data to identify high-priority providers, specialties, encounter types, workflow opportunities, and educational needs.
• Supports the development, implementation, and evaluation of Professional Fee CDI workflows, processes, education schedules, and program initiatives.
• Identifies opportunities to clarify the medical record in a compliant and non-leading manner, consistent with applicable coding, documentation, query, regulatory, and organizational guidelines.
• Creates and delivers specialty-specific education and ongoing feedback based on chart review findings, data analytics, provider performance trends, and identified documentation or coding opportunities.
• Communicates effectively with providers, CDI team members, coding, compliance, and other stakeholders through individual consultations, provider meetings, department or specialty sessions, and other appropriate forums.
• Maintains current knowledge of CMS requirements, official coding guidelines, HCC models, risk adjustment principles, E/M guidelines, clinical documentation requirements, and applicable industry standards.

Job description

Professional Clinical Documentation SpecialistOur website uses cookies to improve your experience. We also use analytic cookies to monitor how people use the website, with a goal of making improvements and making the site more useful.# Careers Home## Professional Clinical Documentation SpecialistApply: Remote: Grand Forks, ND: Full time: Posted Yesterday: R8450**Everything we do is underscored by a why — and that why is one another.****Location:**Altru Health SystemPO Box 6002Grand Forks, ND 58201Pay Range: $73,819.20 - $110,718.40**Summary:**The Ambulatory Clinical Documentation Specialist (CDS) serves as an advisor and expert resource to providers, supporting accurate and complete clinical documentation that reflects patient complexity, risk profiles, and appropriate Evaluation and Management (E/M) service levels. This role supports professional fee billing accuracy, appropriate reimbursement, and compliance with applicable regulatory and industry standards. The Ambulatory CDS identifies clinically relevant information and documentation opportunities through comprehensive chart review. The role focuses on the recapture and identification of chronic conditions represented by Hierarchical Condition Categories (HCCs), which contribute to a patient’s risk-adjusted profile and Risk Adjustment Factor (RAF) score. The CDS also evaluates documentation and medical decision making to identify opportunities to appropriately reflect the level of service provided. The Ambulatory CDS performs pre-visit and post-claim reviews and provides clear, actionable education and feedback to providers regarding clinical documentation, diagnosis coding, E/M level assignment, and billing practices. The CDS collaborates with CDI leadership, clinical documentation colleagues, coding teams, and other organizational partners to improve documentation practices and support compliant patient care and reimbursement.**Essential Job Functions:*** Identifies opportunities to recapture previously documented HCC conditions and identify potential new or “suspect” conditions supported by appropriate clinical indicators and the patient’s medical record. These reviews support accurate patient risk profiles and associated healthcare resource utilization.* Evaluates E/M encounters to identify opportunities related to medical decision-making, patient acuity, E/M level assignment, diagnosis capture, and HCC documentation.* Delivers individualized and group education to providers based on findings from pre-visit and post-claim reviews, data analytics, provider performance trends, and identified documentation or coding opportunities.* Collaborates with Professional Fee CDI leadership, CDI and coding teams, and other organizational partners to support program objectives, coordinate initiatives, and foster effective teamwork.* Uses performance, outcome, and other available data to identify high-priority providers, specialties, encounter types, workflow opportunities, and educational needs.* Supports the development, implementation, and evaluation of Professional Fee CDI workflows, processes, education schedules, and program initiatives.* Identifies opportunities to clarify the medical record in a compliant and non-leading manner, consistent with applicable coding, documentation, query, regulatory, and organizational guidelines.* Creates and delivers specialty-specific education and ongoing feedback based on chart review findings, data analytics, provider performance trends, and identified documentation or coding opportunities.* Communicates effectively with providers, CDI team members, coding, compliance, and other stakeholders through individual consultations, provider meetings, department or specialty sessions, and other appropriate forums.* Maintains current knowledge of CMS requirements, official coding guidelines, HCC models, risk adjustment principles, E/M guidelines, clinical documentation requirements, and applicable industry standards.* Maintains confidentiality in accordance with HIPAA and applicable privacy and security requirements; follows organizational policies and procedures; demonstrates professionalism and respect in all interactions; and pursues ongoing professional growth and development.* Performs other duties as assigned or needed to meet the needs of the department/organization.