Clinical Documentation Specialist I

Description

MSHP seeks a Clinical Documentation Specialist who will support efforts to improve the overall quality and completeness of clinical documentation and coding in outpatient physician practices. They will work closely with physicians, Health Information Management and the Mount Sinai Health Partners team to review and code ambulatory medical records, identify opportunities to improve coding, educate physicians, and act as a liaison between all parties.

ResponsibilitiesFacilitates improvement in the overall quality, completeness and accuracy of medical record documentation and coding.
Reviews charts to assess the clinical status of patients, current treatment plan, and past medical history to identify potential gaps in clinical documentation related to outpatient encounters, with a particular focus on primary care visits.
Performs on-site or electronic coding and clinical validation audits and interpretation of medical documentation to ensure capture of all relevant coding. A particular focus with be on Hierarchical Condition Categories (HCC) coding, which is used by CMS and other payers to determine illness complexity and estimate patient risk of future health care utilization.
Leverages data provided by available information technology (such as billing data) to identify additional opportunities to improve the comprehensiveness and specificity of outpatient coding Communicates and coordinates chart reviews with physician office staff and distributes correspondence related to review.
Analyzes returned CDQI alerts for accuracy and completenessReviews outpatient visit diagnoses and service levels prior to claim submission to ensure they accurately reflect the clinical status of patients and the type of care deliveredProactively solicits clarification from physicians to ensure key aspects of care have been appropriately recorded in the patient’s chartParticipates in data acquisition, development of performance reports and communication of results to physicians, practice managers, and the CDQI leadership teamInteracts regularly with physicians, particularly primary care providers, in the outpatient setting, providing ongoing education regarding compliant documentation and accurate coding, and serves as clinical liaison to the coding departmentIdentifies training needs, prepares summary reports and conducts coaching as appropriate for clinicians and other staff to improve the quality of the documentation to accurately reflect members’ health status.
Monitors coding changes by governmental agencies and other payers; educates practices on coding and compliance issuesMonitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulationsPerforms other related duties.
Qualifications

Education and Experience

High school diploma or general education degree (GED); Associates or greater preferred

Must have a minimum of 3 years coding experience

At least 1 year of HCC Risk Adjustment experience, preferredClinical background in a healthcare setting, preferredCredentials in one or more of the following, required:Certified Coding Specialist (CCS)Certified Risk Adjustment Coder (CRC)Certified Professional Coder (CPC)

Additional Skills and Qualities

Demonstrated experience with front-end process improvement initiativesThorough knowledge of ICD-10, CPT, and HCPCSFamiliarity and understanding of CMS HCC Risk Adjustment coding and data validation requirementsFamiliarity with APC codingExperience with Microsoft Excel and Strong communication and mentoring skillsAbility to communicate clearly and effectively with a wide variety of individuals at all levels of the organizationStrong time management skillsExcellent organization skillsMust possess high degree of accuracy, efficiency and dependabilityExcellent written and oral communication for representation of clear and concise results
Employer Description

Strength through Unity and Inclusion

The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual.

At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create