Job Description

The Clinical Documentation Improvement Specialist (CDIS) uses clinical/nursing 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. 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 expect source and educates members of the patient care team both formally and informally regarding the impact of documentation on patient care, quality metrics, (HCCs), and correct reimbursement.

Duties/Responsibilities:

• Facilitate appropriate clinical documentation through concurrent, prospective, and retrospective medical record review.

• Use clinical knowledge to identify potential gaps in clinical documentation.

• Provide ongoing feedback to physicians and other providers regarding coding guidelines and 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 guidelines.

• Ensure documentation in the medical record follows the official coding guidelines and internal guidelines.

• Create and analyze reports for documentation improvement trending and high-level dashboards for ongoing monitoring and opportunities.

• Travel to assigned outpatient clinic sites to provide availability for inquiries. 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:

• Willing to work as a 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)

• Knowledge of, but not limited to, current coding guidelines and methodologies: HCCs, 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, Word, Excel)

• 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)

• Three (3) years direct clinical nursing experience

• Previous CDI experience required.

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