Specialist, Clinical Documentation Improvement

ArchWell Health; Las Vegas (NV); On-site; USD 90,000 - 120,000; Full time

Job summary

ArchWell Health is seeking a Clinical Documentation Improvement Specialist (CDIS) to enhance accuracy and completeness of clinical documentation in the EMR. You will collaborate with outpatient physicians to ensure coding precision, including HCC capture and ICD-10-CM specificity, serving as a subject matter expert and educator across care teams.

The role requires proactive education for physicians and staff, travel to outpatient centers (minimum one week per month), and ongoing documentation

Qualifications

• Bachelor's degree in Nursing (BSN) required.
• Provider education experience preferred.
• Clinical nursing experience required/preferred.

Responsibilities

• Facilitate appropriate clinical documentation through concurrent, prospective, and retrospective medical record review.
• Ensure documentation in the medical record follows the official coding guidelines and internal guidelines.
• Identify potential gaps in clinical documentation using clinical knowledge.
• Provide ongoing feedback to physicians and other providers regarding coding guidelines and documentation requirements.
• Educate physicians, providers, and clinic staff on clinical documentation compliance and new coding policies.
• Maintain competence on HCC documentation, ICD-10-CM coding, and related guidelines.
• Travel to outpatient centers to assist inquiries and present education materials to provider groups.
• Educate providers on clinical documentation updates and present chart review findings.

Skills

Autonomy

Travel

EMR experience

Coding guidelines knowledge

Medical terminology

Analytical thinking

Critical thinking

Self-motivation

Communication

Education

BSN

Provider education experience

Clinical nursing experience

Tools

EMR systems

Microsoft Office

Job description

ArchWell Health is a new, innovative healthcare provider devoted to improving the lives of our senior members. We deliver best-in-class care at comfortable, accessible neighborhood clinics where seniors can feel at home and become part of a vibrant, wellness-focused community. Our members experience greater continuity of care, as well as the comfort of knowing they will be treated with respect by people who genuinely care about them, their families, and their communities.

Job Summary:

The Clinical Documentation Improvement Specialist (CDIS) uses clinical knowledge and understanding of national coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record. The CDIS works collaboratively with outpatient physicians and advanced practice providers to ensure that the clinical information within the medical record is accurate, complete, and compliant and supports accurate coding. This includes accurate documentation to support the capture of Hierarchical Condition Categories (HCCs) and ICD-10-CM specificity in outpatient visits. The CDIS functions as an SME resource and provides education to members of the patient care team both formally and informally regarding the impact of documentation on patient care, quality metrics, and accurate disease burden reporting.

Duties/Responsibilities:

• Facilitate appropriate clinical documentation through concurrent, prospective, and retrospective medical record review.
• Ensure documentation in the medical record follows the official coding guidelines and internal guidelines.
• Use clinical knowledge to identify potential gaps in clinical documentation.
• Provide ongoing feedback to physicians and other providers regarding coding guidelines and documentation requirements.
• Assist with education of physicians, other providers, and clinic staff relating to clinical documentation compliance as well as new policies and procedures related to coding.
• Maintain competence related to HCC documentation requirements, ICD-10-CM code assignment, and coding and reporting guidelines.
• Travel to assigned outpatient centers to provide availability for inquiries and present education materials to provider groups.
• Provide both formal and informal education to physicians, advanced practice providers, and other key healthcare providers regarding clinical documentation updates and present chart review findings.

Required Skills/Abilities:

• Ability to work both autonomously and within the team - innovation and collaboration is a priority
• Ability to travel -travel required minimum one (1) week per month (Monday - Friday) to assigned clinical site(s)
• Experience with an Electronic Medical Record (EMR) system(s)
• Knowledge of, but not limited to, current coding guidelines and methodologies including CMS HCC models, ICD-10-CM coding guidelines and conventions
• Extensive knowledge of medical terminology, anatomy and pathophysiology, pharmacology, and ancillary test results
• Strong organization and analytical thinking skills - detail oriented
• Proficient with Microsoft Office applications (Outlook, Excel, PowerPoint) *Demonstrates critical thinking skills, able to assess, evaluate, and teach
• Self-motivated and able to work independently without close supervision
• Strong communication skills (interpersonal, verbal and written)

Education and Experience:

• Bachelor's degree in Nursing (BSN)
• Provider education experience
• Clinical nursing experience

Preferred Qualifications:

• CCS, CPC, CRC or similar coding certification
• Three (3+) years HCC/Risk Adjustment coding/documentation experience *Previous outpatient CDI experience

ArchWell Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to their race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected classification