Clinical Documentation Specialist

Posting Number: SRGV
9164

Number of Vacancies: 1

Location: Harlingen, Texas

Department: School of Medicine/ Revenue Cycle

FLSA: Exempt

To promote appropriate clinical documentation through collaboration with the School of Medicine clinical staff by reviewing patientdocuments, assessing for accuracy and educating the patient careteam to ensure guidelines are met and appropriate process is followed.

• Obtains and promotes appropriate clinical documentation throughinteraction with clinical staff and physicians to ensure documentation is complete, accurate and reflects the level ofservice rendered to patients.
• Conducts complex reviews of physician/provider billing compliance activities in accordance with applicable laws, regulations, rulesor policies.
• Performs prospective and retrospective audits of documentation toconfirm compliance with documentation and billing rules and government regulations. Provides feedback and education related toaudit results.
• Reviews documentation by physicians and clinical staff as well aslab results, diagnostic information and treatment plans to assure accuracy.
• Reviews files to identify documentation gaps and requestsclarification from physicians and other caregivers of uncleardiagnoses, patient complications, procedures and clinical documentation.
• Works closely with Revenue Cycle billing/collection staff toensure accurate physician reimbursement is achieved and claimsdenials are reduced by ensuring documentation integrity.
• Educates all members of the patient care team on documentation guidelines on an ongoing basis.
• Develops and presents on-going documentation education for staff including coders, physicians, residents, clinical staff, and allied health professionals.
• Prepares reports, provides supporting evidence and makes recommendations regarding identified documentation and codingdeficiencies or gaps. Identifies trends and provides feedback tomedical staff, coders, and management.
• Acts as a knowledge expert to service providers and codersthrough familiarity with coding conventions.
• Works closely with Revenue Cycle coding staff on Clinical Documentation Improvement (CDI) activities, processes, and procedures.
• Provides education for medical student and resident orientation/development and other times as necessary.
• Presents recommendations for quality management and processesimprovement opportunities regarding workflow and or policies and procedures as necessary.
• Maintains a thorough understanding of CPT, ICD-10 CM, and HCPCScoding principles, and keeps current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates.
• Maintains positive and open communication with physicians,management and Revenue Cycle team.
• Adheres to internal controls and reporting structure.
• Performs other duties as assigned.

General supervision from assigned supervisor.

Direct supervision of assigned staff.

Bachelor's degree in Nursing, Health Information Management orrelated field from an accredited University.

None.

Certified Professional Coder (CPC) from American Academy Professional Coders (AAPC), or Certified Coding Specialist – P (CCS– P) from the American Health Information Management Association(AHIMA), or Certified Professional Medical Auditor (CPMA), or,Attime of hire, Registered Health Information Technician (RHIT) fromthe American Health Information Management Association (AHIMA), or Registered Health Information Administrator (RHIA) from the American Health Information Management Association (AHIMA), or Current State of Texas Professional Nursing License (RN), and must obtain one of the coding…