Job Description

Outpatient Clinical Documentation Specialist

We are searching for an Outpatient Clinical Documentation Specialist -- someone who works well in a fast-paced setting. In this position, you will be responsible for activities which improve the accuracy of facility Outpatient clinical documentation and charging through retrospective chart review and claims audits. Additionally, this includes education with the clinical departments and root cause correction to support accurate charging and coding in compliance with Hospital/Health System policies. The OP CDS assist clinical areas to effectively document services and understand the relationship of documentation, medical necessity, and charging for the services provided in accordance with Hospital/Health System policies and procedures.

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Job Duties & Responsibilities

Chart audits and review of clinical workflows to evaluate opportunities to implement charge capture best practices.

Conducts chart reviews of assigned clinical departments to regularly review the documentation and charge accuracy and to integrate into educational sessions with the clinical departments and medical staff.

Conduct auditing and monitoring of assigned areas.

Performs review of accounts identified as potentially missing charges and conducts additional research to help resolve the areas of opportunity and identify the root cause of the issues causing the missed charges.

Maintains current knowledge of applicable regulatory standards, which may impact utilization of processes and systems.

Lead process improvement and education of clinical, CDI, and coding teams.

Reporting and analysis of data for discussion with clinical or financial teams.

Strong, in-depth knowledge of CPT and HCPCS coding methodologies, as well as an understanding of CMS compliance regulations as they relate to hospital outpatient coding.

Skills & Requirements

Required associate degree with a preferred bachelor's degree.

Required Licenses/Certifications (one of the following):

• MDL - Medical Doctor License by the Texas Medical Board
• RN - Lic-Registered Nurses by the Texas Board of Nursing or Nurse Licensure Compact
• PA - Cert-Physician Assistant by the Texas Medical Board
• RHIA - Cert-Reg Health Inform. Admins by the American Health Information Management Association
• RHIT - Cert-Reg Health Inform. TECH by the American Health Information Management Association
• CPC - Cert-Cert Professional Coder by the America Academy of Professional Coders
• COC - Certified Outpatient Coder by the America Academy of Professional Coders
• CCS - Cert-Cert Coding Specialist by the American Health Information Management Association
• CDEO Certified Documentation Expert Outpatient by the America Academy of Professional Coders
• CDDS DOC - Cert-Cert Clinical Doc. SPCLST by the Association of Clinical Documentation Improvement Specialist
• CDIP - Cert-Clinical Doc. Impr. PROF by the American Health Information Management Association

Required 5 years healthcare related experience with preferred pediatric experience in hospital outpatient charging, coding, and/or revenue capture functions and knowledge of APC and OPPS reimbursement structures.

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