Job Description

The Clinical Documentation Excellence Specialist (CDES) is a pivotal role. The role works closely with providers and healthcare teams to enhance clinical documentation accuracy and ensure ICD-10 coding precision. Your efforts will help us deliver the highest quality of care and accurately reflect the services provided to our patient populations

Duties and Responsibilities

Primary Responsibilities:

• Conduct Timely Reviews: Evaluate outpatient clinical records promptly to identify and address documentation or coding gaps, ensuring accurate representation of clinical severity.
• Enhance Provider Collaboration: Partner with healthcare providers to refine documentation processes and improve point-of-care documentation accuracy.
• Facilitate Clear Communication: Engage with providers through queries in the EMR to clarify documentation needs, provide feedback, and guide improvements in coding specificity and completeness of clinical documentation.
• Lead Improvement Initiatives: Drive efforts to enhance clinical documentation and coding quality through strategic recommendations and collaboration.
• Leverage EMR Software: Document clarification activities using EMR tools and consult with leadership to address provider concerns.

Minimum Qualifications

Required Qualifications:

• Minimum of 3 years of combined, or equivalent, experience as a clinical RN, Foreign Medical Graduate with CDI certification, outpatient certified medical coder with CDI certification.
• High School Diploma or equivalent with relevant vocational training
• Proven experience in Clinical Documentation Improvement.
• Demonstrated ability to build trusted relationships with medical and/or behavioral health providers.
• Ability to work independently, self-motivate, and adapt to change.
• Proficiency working in a Microsoft environment, including Microsoft Word, Excel, PowerPoint, Outlook, and Electronic Medical Records.

Preferred Qualifications:

• Experience applying risk adjustment concepts in CDI reviews.
• CCDS, CDIP, CDEO, or CCS certification.
• Familiarity with eClinicalWorks.
• Eagerness to stay informed about healthcare reform and coding regulations, incorporating changes into chart review and educational responsibilities.

Licensure:

• Not required to maintain an active RN/Medical Assistant license

Working conditions

This job operates in a professional office environment. This role routinely uses general office equipment.

Physical requirements

• Ability to communicate clearly and exchange accurate information constantly.
• Ability to remain stationary for long periods of time.
• Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment.

• Ability to occasionally move objects up to 20 lbs.

Direct reports

None.

All Employees are expected to maintain the security and privacy of all information that is owned by AbsoluteCare or maintained on behalf of the company’s patients, employees, and business partners. Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time. This description reflects management’s assignment of essential functions, it does not proscribe or restrict the tasks that may be assigned. This job description is subject to change at any time.