Clinical Documentation Specialist

1 week ago


Norwood Young America, Minnesota, United States The Christ Hospital Cardiovascular Associates Full time
Clinical Documentation Specialist

At The Christ Hospital Cardiovascular Associates, we are seeking a skilled Clinical Documentation Specialist to join our team. As a Clinical Documentation Specialist, you will be responsible for ensuring the accuracy and completeness of patient records, translating healthcare providers' documentation into coded form, and applying regulatory and organizational guidelines. Your expertise in coding principles and reimbursement rules will enable you to assign appropriate ICD and CPT codes for billing, internal and external reporting, research, and regulatory compliance. You will also communicate with healthcare providers to ensure documentation and coding accurately reflect care rendered, and support their education in areas of CMS regulations, coding, billing, documentation, and administrative guidelines. Additionally, you will manage assigned provider workload in coding workflow within Epic, communicate trends in coding, documentation, and denials to supervisor on assigned providers and/or specialty, and monitor documentation and coding practices to identify and follow up on potential coding-related compliance issues and/or missed revenue potential. If you have a strong knowledge of HCPCS, ICD-10, and CPT coding guidelines, medical terminology, anatomy, and physiology, and are able to accurately code diagnosis, diagnostic, and surgical procedures with a depth of knowledge in Evaluation and Management (E/M) coding within a specialty or service line, we encourage you to apply for this exciting opportunity.

Responsibilities:
  • Translate healthcare providers' documentation into coded form, applying regulatory and organizational guidelines.
  • Assign appropriate ICD and CPT codes for billing, internal and external reporting, research, and regulatory compliance.
  • Communicate with healthcare providers to ensure documentation and coding accurately reflect care rendered.
  • Support healthcare providers' education in areas of CMS regulations, coding, billing, documentation, and administrative guidelines.
  • Manage assigned provider workload in coding workflow within Epic.
  • Communicate trends in coding, documentation, and denials to supervisor on assigned providers and/or specialty.
  • Monitor documentation and coding practices to identify and follow up on potential coding-related compliance issues and/or missed revenue potential.

Requirements:
  • Strong knowledge of HCPCS, ICD-10, and CPT coding guidelines, medical terminology, anatomy, and physiology.
  • Ability to accurately code diagnosis, diagnostic, and surgical procedures with a depth of knowledge in Evaluation and Management (E/M) coding within a specialty or service line.
  • Knowledge of legal, regulatory, and policy compliance issues related to medical coding and documentation.
  • Effective verbal and written communication skills.
  • Research skills, including knowledge of automated analysis tools and online research tools to resolve complex coding and healthcare issues.
  • Ability to effectively work within a team environment, using excellent written, verbal, and presentation skills to share audit findings, risk areas, and compliance issues with coders, office managers, physicians, etc.
  • Maintains confidentiality and protects sensitive data at all times.


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