Clinical Documentation Specialist I - Remote - Mount Sinai Health Partners

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.

Responsibilities

• Facilitates 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 completeness
• Reviews 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 delivered
• Proactively solicits clarification from physicians to ensure key aspects of care have been appropriately recorded in the patient’s chart
• Participates in data acquisition, development of performance reports and communication of results to physicians, practice managers, and the CDQI leadership team
• Interacts 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 department
• Identifies 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 issues
• Monitors activities to ensure that all clinical documentation is in compliance with State and Federal payer regulations
• Performs 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, preferred
• Clinical background in a healthcare setting, preferred
• Credentials 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 initiatives
• Thorough knowledge of ICD-10, CPT, and HCPCS
• Familiarity and understanding of CMS HCC Risk Adjustment coding and data validation requirements
• Familiarity with APC coding
• Experience with Microsoft Excel and Strong communication and mentoring skills
• Ability to communicate clearly and effectively with a wide variety of individuals at all levels of the organization
• Strong time management skills
• Excellent organization skills
• Must possess high degree of accuracy, efficiency and dependability
• Excellent written and oral communication for representation of clear and concise results

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