About the job
Job Summary
The Clinical Documentation Excellence Specialist (CDES) is a pivotal role. The role works closely with providers and healthcare teams to enhance clinical documentation accuracy and ensure ICD-10 coding precision. Your efforts will help us deliver the highest quality of care and accurately reflect the services provided to our patient populations
Duties And Responsibilities
Primary Responsibilities:
- Conduct Timely Reviews: Evaluate outpatient clinical records promptly to identify and address documentation or coding gaps, ensuring accurate representation of clinical severity.
- Enhance Provider Collaboration: Partner with healthcare providers to refine documentation processes and improve point-of-care documentation accuracy.
- Facilitate Clear Communication: Engage with providers through queries in the EMR to clarify documentation needs, provide feedback, and guide improvements in coding specificity and completeness of clinical documentation.
- Lead Improvement Initiatives: Drive efforts to enhance clinical documentation and coding quality through strategic recommendations and collaboration.
- Leverage EMR Software: Document clarification activities using EMR tools and consult with leadership to address provider concerns.
Minimum Qualifications
Required Qualifications:
- Minimum of 3 years of combined, or equivalent, experience as a clinical RN, Foreign Medical Graduate with CDI certification, outpatient certified medical coder with CDI certification.
- High School Diploma or equivalent with relevant vocational training
- Proven experience in Clinical Documentation Improvement.
- Demonstrated ability to build trusted relationships with medical and/or behavioral health providers.
- Ability to work independently, self-motivate, and adapt to change.
- Proficiency working in a Microsoft environment, including Microsoft Word, Excel, PowerPoint, Outlook, and Electronic Medical Records.
Preferred Qualifications
- Experience applying risk adjustment concepts in CDI reviews.
- CCDS, CDIP, CDEO, or CCS certification.
- Familiarity with eClinicalWorks.
- Eagerness to stay informed about healthcare reform and coding regulations, incorporating changes into chart review and educational responsibilities.
Licensure
- Not required to maintain an active RN/Medical Assistant license
Working conditions
This job operates in a professional office environment. This role routinely uses general office equipment.
Physical Requirements
- Ability to communicate clearly and exchange accurate information constantly.
- Ability to remain stationary for long periods of time.
- Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment.
- Ability to occasionally move objects up to 20 lbs.
Direct reports
None.