Share Email Opening Title Clinical Documentation Improvement (CDI) Specialist  Description Job Overview: The CDI Specialist will have strong leadership skills with the ability to proactively educate providers and other clinician members of the Tar River Health Alliance Accountable Care Organization (ACO) in recording medical diagnoses in the health record. The position will improve data quality, appropriately risk stratify the population of the Tar River Health Alliance and better patient care by reviewing medical records concurrently with providers to determine if there are gaps in documentation. Will query the providers about any gaps to clarify the documentation to support and record appropriate ICD-10 diagnosis codes. The CDI Specialist will ensure accuracy and quality among medical coders, providers, nurses, billing teams, and other healthcare staff and also work collaboratively with Care Coordination teams to help identify and close care gaps. An understanding of risk adjustment models and hierarchical condition category (HCC) coding is necessary. Essential Job Functions, Duties, and Responsibilities: The following list of duties is not intended to be restrictive or all inclusive. The fact that certain duties may not be listed does not limit the assignment of additional and/or other duties. Identify opportunities to impact risk adjustment factors through documentation of complicating and comorbid, or major complicating and comorbid conditions and formulate a provider query based on query guidelines with timely provider follow-up. Complete provider clarification queries per guidelines for instances in which documentation in the medical record is ambiguous, incomplete, or conflicting, and provide timely provider follow-up as needed. Facilitate communication and collaboration among coders, providers, and nurses to identify documentation opportunities that appropriately reflect severity of illness and risk of mortality. Recommend strategies for improving record keeping processes, attend meetings to present current clinical documentation trends, findings, and provide education on the impacts of clinical documentation. Applies knowledge of medical terminology and medical procedures to properly evaluate clinical documents. Ensure all clinical documents are in compliance with federal laws in terms of composition. Analyzes medical information to assist healthcare staff in providing superior services for patients. Interprets clinic reports to identify health-related patterns and assists in addressing patient health problems. Works with physician and clinic leadership to develop and monitor key performance indicators for clinical documentation. Meets with clinical staff and providers to explain reports. Prepares written reports for internal monitoring and compiles data for reporting Tracks information on diseases. Conducts research and performs administrative duties. Takes continuing education courses and stays up-to-date on changes in laws governing clinical documentation. Perform other duties as assigned.   Position Requirements Minimum Qualifications: Requires a minimum of 3 years of clinical coding experience in a hospital or physician practice environment with at least one of two types of credentials: HIMS professional candidates must be credentialed as an RHIA, RHIT, CPC, or CCS and have experience in ICD-10 CM coding. HIM management experience is a plus. Clinical Candidates must be credentialed and hold current NC license as an LPN, RN, BSN, (C-CDIS is a plus)   Must have: Excellent oral and written communication skills. Be organized; able to set priorities and meet deadlines. Proficient computer skills in eCW, Word, and Excel Must be able to work in a team environment and exhibit flexibility and enthusiasm in learning new information and developing new skills quickly. Knowledge of pertinent Federal, State, and local laws, codes, and regulations Knowledge of pertinent Federal, State, and local laws, codes, and regulations.     About the Organization   This position is currently not accepting applications. To search for an open position, please go to http://Boice-WillisClinicPA.appone.com

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