Outpatient Clinical Documentation Improvement Specialist
Remote · Saint Marys, Ohio, United States
Job Summary
Outpatient Clinical Documentation Improvement Specialist responsible for performing concurrent reviews of patient records to ensure complete, accurate, and specific clinical documentation. Focus on understanding coding guidelines, clarifying conflicting or incomplete documentation by querying providers, and educating the care team to reflect true care, reimbursement, illness severity, and risk of mortality. Drives improvements in documentation quality, supports accurate coding (ICD, CPT, HCPCS Level II), and ensures compliance with payer policies and regulations. Collaborates with physicians, nursing staff, and practice coding staff to optimize documentation, reduce denials, and support quality and risk adjustment initiatives. Provides provider education and facilitates communication to support coding accuracy, audit readiness, and interdepartmental collaboration.
Required Qualifications
- Associate’s degree in Healthcare, Nursing or related field, or equivalent combination of education & experience
- Must have training in medical terminology, anatomy, and physiology
- Must have training and certification in coding, or equivalent combination of education and experience
- Must possess certification; CDEO, CCDS-O, CPC, or CCS with coding or clinical documentation integrity experience; must agree to obtain CDEO or CCS-O within first year of employment
- In-depth knowledge of medical record content
- In-depth knowledge of ICD & CPT coding guidelines
- Experience with compliant healthcare documentation, HCC coding requirements, alternate payment models in multi-facility environments
- Basic computer skills
- Experience with coding software (encoders)
- Knowledge of LDC/NCD and Quality Measures
- Knowledge of coding guidelines
- Excellent observation, analytical thinking, problem solving, and presentation skills
- Ability to balance multiple tasks and meet deadlines
- Ability to communicate effectively via remote Teams application
- Manual and finger dexterity; sitting for extended periods; able to travel to provider practices or group meetings as needed; vision and hearing within normal range; ability to work under stressful conditions
- Excellent interpersonal skills; strong initiative, judgment, and problem-solving skills; ability to develop positive working relationships across the organization
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