Clinical Doc Improvement Speci

Purpose of Position :
The CDIS is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the quality of the physicians’ clinical documentation.

• Conduct Risk Adjustment Reviews of medical records to verify whether diagnosis codes are supported by the documentation and ensure with ICD-10-CM Guidelines for Coding and Reporting.
• The diagnosis codes for each chronic or major medical condition have been captured correctly.
• Review for clinical indicators and query providers to capture the severity of illness of the patient.
• Conduct medical chart review to identifying opportunities for improving individual member risk adjustment score accuracy and communicate the same to the physician or his /her designee.
• Obtain appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers.
• Educate practice office physicians and staff on clinical documentation needs, changes to clinical documentation guidelines and coding issues.
• Conduct follow up review of clinical documentation to ensure proper clinical information is documented in the patient’s record.
• Generate accurate and timely status reports for physicians & leadership.
• Performs other work related duties as assigned or requested.

Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects Cape Cod Healthcare’s commitment to CARES: compassion, accountability, respect, excellence and service.

• Associate’s Degree in a relevant field preferred or combination of equivalent education and experience.
• Knowledge of clinical documentation guidelines and CDI program implementation experience preferred.
• Certified Professional Coder (CPC) certification required.
• Knowledge of disease process, medical terminology, ICD-10-CM and CPT codes.
• Knowledge of ICD-10 principles and further documentation specificity highly preferred.
• CCDS or CDIP in an active status with AHIMA or ACDIS is preferred.
• Excellent organizational, analytical, writing and interpersonal skills.
• Dependable and self-directed.
• Critical thinking, problem solving and deductive reasoning skills.
• Proficient computer skills – familiarity with Windows based software programs.
• Knowledge of Medicare Part A and Part
  
  B.
• Knowledge of regulatory environment.
• Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with physicians, fellow employees & all customers.
• Management/supervisory experience preferred.

Massachusetts-Hyannis

Department : HCI-PO - PHO

Hiring Pay Range : $ 0 - $ 0