Outpatient Clinical Documentation Specialist

Op Clin Documentation Spec

Inova Benefits and Perks:

• Health, Vision, and Dental Coverage
• Tuition reimbursement and Educational Assistance
• Student loan assistance - up to $10,000!
• Paid parental leave for birth/adoption of a child
• Retirement benefits with match from day one
• Exclusive savings opportunities to in-store events, theme parks, discounts, movie tickets and local offerings and so much more!
• Competitive salary: Pay based experience
• Amazing Paid Time Off: Accrue PTO hours on your very first day of work

See Full List of Benefits Here: 2024 INOVA BENEFITS GUIDE

Inova Health System is seeking an Clinical Documentation Specialist to join the Outpatient CDI team! This role is full-time Monday to Friday remotely.

Requirements for consideration:

• High School or GED
• Five (5) years healthcare physician/facility related experience in auditing.
• Completion of an approved coding or health information technology program with current certification(s), such as RHIA, RHIT, CCS, CCS-P or CPC, CPMA, CRC, with Clinical Documentation certification required within 2 years of hire. ***Preferred to have Certifications Upon Start***

Job Responsibilities included but not limited to:

• Conducts initial and follow-up concurrent reviews of medical records for assigned patients in the timeframe and frequency defined for productive work.
• Identifies appropriate clinical documentation to support HCC, ICD-10-CM specificity, HCPCS, CPT, Modifiers, and medical necessity of ambulatory visits.
• Identifies the need to clarify incomplete or conflicting documentation in medical records and prepares a compliant written query for the responsible treating physician. Option also exists to interact with responsible treating physicians via a verbal query in accordance with compliance requirements. Continues to track the occurrence of physician response documented in the medical record..
• Documents findings on worksheets, denoting all key information utilized in the tracking process. Enters data into Clinical Documentation Integrity System (CDIS) Outpatient when applicable.
• Consistently meets established productivity targets for record review.
• Works with the Program Manager and responsible physician administrator or physician advisor regarding treating physician compliance issues such as non-response to queries and questionable clinical validity of documented diagnoses.
• Maintains competency in the use of CDIS to process daily work lists and results of record reviews.
• Maintains competency in the use of Coding and Reimbursement System tools and electronic coding references to code and assign all codes applicable to the encounter including modifiers.
• Analyzes clinical status of patients, current treatment plan, and past medical history and identifies potential gaps in physician documentation.
• Routinely provides one-on-one education to new and established physicians, advanced practice providers, and other key healthcare providers regarding the need for accurate, specific, and complete clinical documentation in the patient's medical record.
• Interacts regularly with physicians, in the outpatient setting, providing ongoing education regarding compliant documentation.
• Assists with analysis, trending, and presentation of audit/review findings, potential issues, and their root cause.
• Maintains HCC documentation requirements, ICD-10-CM code assignments and coding guidelines.
• Develops and conducts education to all other providers (nurses, case managers, coding staff, compliance) on documentation requirements, program findings, and opportunities for improvement.
• Maintains integrity of data collection by ensuring accurate data entry.
• Demonstrates ability to interpret and incorporate CDIS data into formal presentations for physicians and other hospital providers who impact this program.
• Oversees assigned department or functional area to ensure it is performing effectively, which may include but not limited to, hiring and training team members, creating and implementing business strategies, managing performance of team members, and delegating tasks.
• May perform additional duties as assigned.