Clinical Documentation Specialist - Professional Ambulatory

We’re hunting for a Professional Ambulatory Clinical Documentation Specialist, someone who’s ready to be part of the best ranked children’s hospital in Texas, and among the best in the nation. In this position, you will be responsible for the reviewing, education, development, and training of our Physicians and staff as it relates to reimbursement and CPT and ICD coding compliance.

Think you’ve got what it takes?

• Develops and implements a method by which each TCPA & TCPSO physician has a representative sample of his/her medical records reviewed on a routine and frequent basis.
• Provides feedback to physician and Director on the educational opportunities found from the reviews. Recommends improvement opportunities to documentation practices and coding changes to physician based on information.
• Provides feedback to the Director on any Medicaid compliance issue found from the reviews.
• Develops and implements training programs for Physicians, Front Office, and CBO staff to reinforce and/or change the documentation and coding behaviors found from the review.
• Educates and reinforces the most appropriate documentation used to optimize quality and reimbursement that TCPA & TCPSO physicians utilize. Where appropriate, this should include education on coding guidelines when quality documentation is already present but not coded to the appropriate level.
• Focused on root cause identification and process improvement specific to documentation accuracy and completeness.
• Engages in process and quality improvement initiatives.
• Reviews and interprets the Federal Registry and other relevant publications on a current and regular basis to be aware of coding changes that may affect TCPA & TCPSO as well as the industry.
• Responds directly to all telephone and written requests for documentation and coding information accurately and timely.
• Acts as a risk adjustment documentation and coding resource, including education and physician engagement.

• Required associate degree with a preferred bachelor's degree
• Four years of healthcare experience will substitute for the required associate degree
• Required Licenses and Certifications
  • CPC - Cert-Cert Professional Coder American Academy of Professional Coders (AAPC)
  • CCDS DOC - Cert-Cert Clinical Doc. SPCLST Association of Clinical Documentation Improvement Specialist (ACDIS)
  • CDIP - Cert-Clinical Doc. Impr. PROF American Health Information Management Association (AHIMA)
  • CCS-P - Cert-CCS-P Physician Based American Health Information Management Association (AHIMA)
  • CIPC - Certified Inpatient Coder American Academy of Professional Coders (AAPC)
  • COC - Certified Outpatient Coder American Academy of Professional Coders (AAPC)
  • CDEO Certified Documentation Expert Outpatient American Academy of Professional Coders (AAPC)
  • CCDS-O Certified Clinical Documentation Specialist Outpatient Association of Clinical Documentation Improvement Specialist (ACDIS)
• Preferred Pediatric Experience