Clinical Documentation Improvement Partner

Summary

Join Evergreen Nephrology as a Clinical Documentation Improvement Partner and play a vital role in transforming kidney care. Partner with physician offices to translate healthcare documentation into standardized codes, ensuring accurate coding and billing. Serve as a subject matter expert in coding and documentation, accurately coding diagnoses, and ensuring documentation supports appropriate levels of care. Maintain a high productivity rate, communicate with healthcare providers to clarify documentation, and issue queries when necessary. Stay updated on coding guidelines and regulatory changes, assist in improving clinical documentation quality, participate in performance improvement projects, conduct medical record audits, and provide ongoing education to clinical staff. Collaborate with various departments to optimize the documentation improvement process and develop training programs to address documentation deficiencies.

Requirements

• High school diploma, GED, or suitable equivalent
• 2+ years recent outpatient medical coding experience
• Must possess one of the following coding credentials: CPC, CRC, CCS, or similar
• Strong knowledge of ICD-10-CM, Category II and CPT coding
• Proficiency in medical terminology, anatomy, and physiology
• Familiarity with healthcare laws, regulations, and other applicable guidance, such as Medicare, Medicaid, HEDIS, and CMS performance measures
• Knowledge of risk adjustment methodology and Hierarchical Condition Categories (HCC)
• Ability to analyze complex medical records, identify documentation gaps, and determine appropriate queries
• Strong written and verbal communication skills
• Meticulous attention to detail that ensures a high level of accuracy in your work product
• Ability to identify discrepancies in clinical documentation and partner with providers to resolve issues efficiently
• Familiarity with electronic health records (EHR), CDI software, and healthcare documentation systems is essential
• You have the tenacity required to drive initiatives forward, overcome obstacles, and achieve goals despite challenges
• Intermediate skills with MS Office Suite of products including Outlook and Teams
• You have the ability to work effectively in a primarily remote environment: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wired to the house internet (Cable, Fiber, or DSL) and hardwired to the internet device is recommended

Responsibilities

• Accurately code diagnoses based on documented information, ensuring compliance with regulatory requirements and that the assigned codes accurately represent the clinical information documented by the provider
• Ensure documentation supports appropriate level(s) of care and severity of illness when applying ICD-10, CPT, and other relevant codes for billing and regulatory compliance
• Maintain a 95% productivity rate
• Communicate with physicians and other healthcare providers to clarify documentation, ensuring that diagnoses and procedures are properly documented in compliance with clinical standards
• Issue queries to healthcare providers when documentation appears ambiguous, incomplete, or inconsistent, requesting clarification or additional details be added to the medical record to ensure accurate documentation
• Ensure that the queries are compliant with industry standards and regulatory guidelines
• Stay updated on current coding guidelines, clinical protocols, and regulatory changes, including Medicare and Medicaid guidelines on billing and coding, to support provider compliance therewith
• Assist in improving the quality of clinical documentation to support various quality initiatives, such as HEDIS, CMS, and other contractual or enterprise-initiated performance metrics
• Participate in performance improvement projects aimed at improving documentation practices and outcomes
• Conduct audits of medical records to identify trends in documentation, both positive and negative, to help the organization improve documentation practices and provider education efforts
• Provide ongoing education to clinical staff, coders, and other healthcare providers on best practices in clinical documentation, coding guidelines, and regulatory compliance
• Develop training programs to address documentation deficiencies and improve overall documentation quality
• Collaborate with departments such as compliance, revenue cycle, and quality management to optimize the documentation improvement process

Preferred Qualifications

• Associate’s or Bachelor‘s Degree in Nursing (BSN/ASN), Health Information Management (HIM) or related healthcare field
• HCC Coding experience

Benefits

• Competitive base pay with bonuses
• Paid time off starting at 4 weeks for full-time employees
• 12 paid holidays per year
• Medical, dental, vision and life insurance, including an HSA with employer match
• Reimbursement for continuing medical education
• 401(k) with match
• Paid parental leave
• A robust training and development program that starts with onboarding and continues throughout your career with Evergreen Nephrology