Ambulatory Clinical Documentation Improvement Specialist

Job Description

Job Description

JOB SUMMARY:  
The Ambulatory Clinical Documentation Improvement Specialist (CDS) will assist providers in capturing the clinical documentation needed to accurately reflect patient acuity and support the appropriate diagnosis and E/M level for professional fee billing. The Ambulatory CDS will focus on two primary tasks, the appropriate documentation and assignment of diagnoses and E/M levels and the capture or identification of chronic conditions reflected in Hierarchical Condition Categories (HCCs).

Appropriate and accurate ICD-10 CM diagnosis assignment and sequencing as well as appropriate E/M level assignment is important for both revenue capture and compliance.  For this task, this position will be responsible for onboarding new providers, explaining the audit and CDI activities of the Health System, and performing routine audits of a provider’s documentation to support his/her diagnosis capture and sequencing and E/M assignment for the visit.  These audits and any education provided will be tracked and reported to Physician Enterprise leadership.

HCCs directly impact the patient risk adjusted profile (RAF score) calculated by the associated risk-adjusted plans.  For this part of the role, the Ambulatory CDS will be responsible for completing pre-visit chart views for scheduled patients.  Pre-visit reviews are intended to identify documentation opportunities for the provider to recapture previously documented HCCs diagnoses or new HCCs not previously captured that are identified by reviewing past medical records. The Ambulatory CDS will coordinate with Provider Liaisons and other colleagues from the Ambulatory CDI Program on education and training geared toward improving clinical documentation.  This position supports a multi-facility / multi-location health system, and as such, requires the ability to travel to various CHS facilities throughout the Health System.