Clinical Documentation Specialist

Position Summary:

Under the guidance of the Manager for Billing, Coding, & Provider Documentation this position will support internal & external clinical and operational coding initiatives at Commonwealth Care Alliance (CCA). The Clinical Documentation Sr. Specialist will serve as a primary resource in evaluating medical encounter notes/records housed either at CCA or at contracted primary care sites to ensure completeness, accuracy, and compliance with the International Classification of Diseases Manual - Clinical Modification (ICD-10-CM) and the American Medical Association's Current Procedural Terminology manual (CPT). The CDIS will be responsible for educating and advising CCA internal departments and CCA's primary care sites in Medicaid and Medicare documentation requirements as well as guiding in the identification and application of appropriate ICD-10 CM & CPT/HCPCS corrective coding techniques to capture CCA member's acuity/chronic disease profile.

Supervision Exercised:

• No

Essential Duties & Responsibilities:

• Evaluates medical record documentation and corrective coding to optimize reimbursement and ensure adequate collection of clinical quality data; ensures diagnostic and procedural codes and other documentation accurately reflect and support services rendered as well as data comply with legal standards and guidelines; interprets medical information such as diseases, symptoms and treatment, and diagnostic descriptions and procedures for a given visit in order to accurately assign and sequence the correct ICD-10-CM and CPT codes and identify all appropriate codes based on CMS HCC categories
• Provides technical guidance to primary care site in identifying and resolving issues or errors, such as incomplete or missing records and documentation, ambiguous or nonspecific documentation, or codes that do not conform to approved coding principles/guidelines; educates and advises staff on proper code selection, documentation, procedures, and requirements
• CPC/CCS and CRC required
• Maintains a 95% quality audit accuracy rate every month
• Attends all clinical site meetings providing support & coding education as needed
• Reviews bulletins, newsletters, and periodicals, and attends workshops to stay abreast of current issues, trends, and changes in the laws and regulations governing medical record coding and documentation
• Identify training needs, prepare training materials, and conduct education training programs related to corrective Diagnosis & CPT documentation requirements
• Develops and updates procedure manuals to maintain standards for correct coding, minimize the risk of fraud and abuse, and optimize revenue recovery
• Serve as a resource for primary care site to answer questions regarding risk adjustment, corrective CPT coding, Medicare & Medicaid coding guidelines and updates
• Maintains all related CDI & Coding Credentials certifications and CEU requirements
• Additional duties as identified

Working Conditions:

• Predominantly office setting with some Remote work based opportunity
• Includes walking and standing for short periods of time, sitting for long periods of time, hand dexterity, clear hearing and speaking ability.

Required Education:

• Associate's Degree or equivalent experience
• Possession of Certified Coding Specialist designation (CCS, CCS-P, CCA from AHIMA) or Certified Professional Coder (CPC), and Certified Risk Adjustment Coder (CRC) from the American Association of Professional Coders (AAPC) is required

Desired Education:

• Bachelor's Degree -preferred

Desired Licensing:

• Licensure with the Commonwealth Of Massachusetts as a LPN or RN a plus

Required Experience:

• 2-4 years
• 2-3 years in a Health care setting working with codes and reviewing documentation.
• 2+ years clinical experience working within a health care setting performing clinical documentation and CPT/HCPCS coding activities

Desired Experience:

• 2+ years' experience in medical coding in ambulatory Care, Outpatient or Home Care Setting a plus

Required Knowledge, Skills & Abilities:

• Ability to interact and communicate with providers in a collegial manner.
• Up-to-date knowledge of: ICD-10-CM, CPT and E&M coding guidelines and Medicaid and Medicare reimbursement guidelines
• Up-to-date clinical knowledge to be able to efficiently and concurrently review medical records, understand clinical picture of the patient condition, and identify opportunities for improved documentation.
• Ability to create and maintain strong interpersonal relationships with the Clinical and Administrative Staff
• Well-developed verbal and written communication skills to effectively and professionally communicate with clinical staff about review findings associated with coding and documentation
• Ability to develop and deliver education programs on clinical documentation improvement for the Clinical Staff.
• Knowledgeable of health care insurance claims practice and compliance
• Familiarity with physician-specific regulations and policies related to documentation and coding
• Knowledge of Medicare Risk Adjustment Documentation with Certified Risk Adjustment Coder (CRC) certification or in process of obtaining this certification
• Experienced to Proficient in Microsoft office Products
• Experienced in working with EMR's (eCW, Epic, etc.)
• Ability to multi-task and function in multifaceted settings
• Attention to details and with consistent and timely follow- up.

Language(s):

• English
• Secondary language is not required but a plus