Ambulatory Clinical Documentation Specialist

2 weeks ago

Newtown Square, Pennsylvania, United States Trinity Health Full time $60,000 - $120,000 per year
Employment Type:Full timeShift:Day ShiftDescription:

Trinity Health Mid-Atlantic, is looking for a CIN Ambulatory Clinical Documentation Specialist to join our team

Employment Type:

Full Time

Schedule:

This is a full-time remote position. Day shift, Monday - Friday.

Specific schedule to be further discussed by department based on needs.

Job Description:

Utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator, and consultant. Facilitates the overall quality, completeness, accuracy, and integrity of medical record documentation through extensive record review. 

Through interaction with physicians and other members of the healthcare team, achieves appropriate clinical documentation to support code assignment and burden of illness, medical necessity, severity of illness, risk of mortality and level of services rendered to all patients. Participates in the development and delivery of education for providers and members of the healthcare team.

  • Demonstrates understanding of appropriate clinical documentation to ensure the severity of illness, risk of mortality, quality indicators are accurately reflected in the health record.

  • Assists in overall quality, timeliness, and completeness of the health record to ensure appropriate data, provider communication and quality outcomes and identifies incomplete or inconsistent documentation in the record which impacts HCC or other risk score coding.

  • Conducts pre and post encounter medical record review coding and documentation for accuracy and completeness.

  • Identifies opportunities for increased coding accuracy and communicates with provider prior to claim submission to ensure accurate burden of illness identification.

  • Conducts medical record audit of selected patient health records to address legibility, clarity, completeness, consistency, and accuracy of clinical documentation to support burden of illness.

  • Provides training to health care professionals in ICD-10-CM, CPT, and HCPCS Coding Guidelines, modifier guidelines, documentation guidelines, medical terminology, and disease processes.

Requirements:

  • Must possess a Degree in Nursing (BSN, AS or Diploma), or an Advanced degree in nursing or medical field such as MD, DO, NP/APN or PA.

  • In the absence of a college degree, must have 3 or more years' experience as a clinical documentation specialist

  • If RN, Current Registered Nurse License

  • Certified Coding Specialist (CCS), Certified Clinical Documentation Specialist (CCDS), or Certified Documentation Improvement Professional (CDIP) (or obtained within 6months of hire)

  • Minimum of one year Risk Adjustment Validation experience

We offer a competitive salary and comprehensive benefits including:

  • Medical, Dental, & Vision Coverage (Effective First day of Hire)

  • Retirement Savings Program

  • Generous Paid Time Off

  • Tuition Reimbursement

  • Free Parking

  • And more

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

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