To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
The OP Clinical Documentation Improvement Specialist (OP-CDIS), working under the direction of the OP Coding Supervisor, utilizes compliant documentation improvement principles and coding expertise to identify areas of opportunity that impacts the quality and the completeness of the medical record documentation. Through current, prospective, and retrospective evaluation of the medical record documentation the OP-CDIS will be responsible for working collaboratively with the clinical team members to clarify documentation via clinically compliant physician queries, support medical necessity, and provide education with the end goal of achieving improved documentation results and reduction of unnecessary denials for the organization. The overall outcome will be documentation that accurately and completely captures the clinical picture/severity of illness/patient complexity while providing specific and complete information to be used in coding and reporting of outcomes for the facility and the physicians. The OP-CDIS utilizes knowledge of coding guidelines, coding/billing compliant practices, payer policies, Hierarchical Condition Categories (HCCs), policy manuals/coverage determinations, denial data, and clinical knowledge to identify opportunities that are compliant and appropriate to achieve maximum results. This individual also supports other team members, shares knowledge and role models the professional standards of behavior.
- 1. Performs systematic chart reviews on a daily basis to improve the overall quality and completeness of the clinical documentation. Identifies the most appropriate CPT and ICD-10-CM diagnoses codes that accurately reflect the services performed and identifies when additional steps are needed in an effort to potentially prevent unnecessary denials using a wide range of references such as various clinical payer policies, LCD/NCDs, etc.
- 2. Compliantly queries physicians and clinicians to clarify clinical documentation by applying coding and/or clinical knowledge to accurately support medical necessity, procedure codes, and accurate HCC capture assignment.
- 3. Consistently maintains quality and productivity standards: Meets daily review, query and query response targets.
- 4. Understand risk adjusted payment methodologies, HCC assignment and payment methodology, professional coding and billing, outpatient facility coding and billing, APC assignment, and OPPS reimbursement methodology and shares this knowledge with colleagues and clinical team members.
- 5. Educates medical staff on documentation requirements, documentation improvement areas, and coding guidelines to accurately reflect the complexity and shows the medical necessity of the visit
- 6. Resolves all OP-CDIS assigned work and provides feedback and education to claim analysts and OP Coding Supervisor.
- 7. Participates, as needed, in providing 1:1 and/or group education to clinical team members and/or colleagues in coding/claim edits/denials and/or clinical documentation improvement activities.
- 8. Recognizes or works collaboratively with others to identify the key issues resulting in provider liable accounts and makes recommendation to improve the entire process in order to effectively reduce the number of these accounts. Looks for ways to continually to improve the process that will result in a lower incidence of provider liable accounts. Is actively involved in appeals and/or denials as needed to support this work efforts.
- 9. Develops and delivers education to the medical staff, clinicians, and department team members team members in the application of coding guidelines and practices, proper documentation techniques, etc. using a variety of teaching methods including, but not limited to: small group presentations, department meetings, physician in-services in person and remotely through the use of technology.
- 10. Shadows Inpatient CDI team members to identify commonalities and areas of opportunity in the work performed.
- 11. Leads efforts to evaluate HCC and procedure documentation and provides recommendations to improve documentation and coding.
- 12. Collaborates with clinical staff, ITS, and others on identifying software and template improvement opportunities
- 13. Leads and/or actively participates in meetings. Actively participates in department performance improvement and employee engagement activities.
- 14. Performs all other duties or special projects requested by Coding leadership and proactively communicates any problems that arise to maintain a smooth operation of the department.
- 15. Exhibits enthusiasm for the profession, embraces educational opportunities and department support offered and remains engaged in the goals and vision of the department. Role models the professional standards of behavior and encourages staff to do the same.
Two (2) years of college or equivalent. Working knowledge of human anatomy/physiology and disease processes through coding knowledge or education is needed. Health Information Management or Nursing education a plus.
Five (5) years of outpatient facility coding in multiple coding service lines or billing related claim edit experience, or strong medical background with 3-5 years' acute clinical experience. Thorough knowledge of clinical documentation requirements, coding, guidelines, and regulatory requirements related to coding and coding compliance. Ability to communicate effectively with physicians verbally and in writing.
Epic HB billing knowledge preferred.
Certified coder through AHIMA or AAPC (CCS, CCS-P, CPC, or COC) or LPN/RN with clinical experience and required to obtain coding certification within 6 months from hire. CDOE certification after 2 years of experience. CRC certification a plus.
Very strong communication skills, written and oral, for communication with Medical Staff and other healthcare professionals are a must. Ability to perform well in a fast-paced team environment and to manage time effectively. In-depth knowledge of medical terminology, anatomy, physiology, and disease process. Comprehensive understanding of ICD-10-CM classification systems. Expertise in governmental payment policies and regulations including medical necessity, NCCI, OCE, and MUE policies and procedures. Must be able to train, educate, present and share knowledge and information.