Outpatient Clinical Documentation Specialist

Overview

The Outpatient Clinical Documentation Specialist is responsible for activities which assist the hospital with processes for complete and accurate capture of documentation and charges for the facility outpatient services rendered.   The Outpatient CDS provides assistance with processes and education with the Clinical Departments to support accurate documentation and charging in compliance with company policies. The Outpatient CDS assists clinical areas to effectively document services and understand relationship of documentation, medical necessity, coding and charging for all services provided. The Outpatient CDS provides education and training of staff on clinical documentation, coding and charging for facility outpatient services in accordance with policies and procedures

Responsibilities

Conduct chart reviews of clinical departments to regularly review the documentation and charge accuracy and to integrate into educational sessions with the clinical departments and medical staff

Performs shadowing and coaching with key stakeholders in the clinical departments to facilitate adoption of best practices and improve documentation and charging accuracy

Takes ownership and initiative to build upon documentation improvement and charge capture processes for identified areas of opportunity

Provides reporting and feedback to the clinical departments based on claim accuracy and chart reviews to encourage greater understanding and ownership of documentation and charge accuracy

Performs review of accounts identified as potentially missing charges and conducts additional research to help resolve the areas of opportunity and identify the root cause of the issues causing the missed charges

Coordinates with clinical departments including Coding, PFS, CDM, Finance and others to review, correct claims and identify root cause of missing charges

Performs analysis of patient clinical and billing data to identify documentation, coding and charging opportunities, summarizes data and prepares summary materials for discussion with clinical and finance teams

Fosters teamwork and utilizes strong team building measures

Develops and maintains project plans and project tracking, including documentation of project meetings and project issues lists

Maintains current knowledge of applicable regulatory standards, which may impact utilization of processes and systems

Work with finance to track revenue indicators and corresponding action plans.

Performs revenue optimization functions including:

Review of accounts for potential missing documentation, coding and charging

Identify root cause of missing charges

Educate Clinical and Ancillary Departments

Perform process improvement activities aimed at revenue optimization

Coordinate with the Clinical Departments, Coding, CDM, and other key stakeholders to address and resolve root cause issues

Auditing and monitoring of defined areas

Maintains strict confidentiality of all patient, employee and physician information according to HIPAA guidelines

Other Job Responsibilities

Shares in the Hospital’s/Health System’s vision, demonstrates its values, supports its philosophy and is sensitive to its mission.  Demonstrates knowledge of and follows Departmental, and Hospital policies and procedures as outlined in the Employee Handbook, and Policies and Procedures Manual.

Seeks out opportunities for individual growth and development, including attending various meetings, conferences, courses, seeking certifications (i.e. CPC), as required.

Uses tact and sensitivity when communicating with patients, visitors, co-workers, and other Health System personnel.

Serves on department and/or institutional committees as requested

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Mission, Vision, and Values including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned

Qualifications

MINIMUM KNOWLEDGE, SKILLS, EXPERIENCE REQUIRED

• Education: Bachelor’s degree or over 5 years related healthcare experience in lieu of degree.
• Licensure / Certification: RN, LPN or RHIA, RHIT, CPC, COC, or CDEO credential preferred.
• Experience: Five or more years of healthcare knowledge typically obtained from experience as a clinical caregiver or manager, coding specialist, and/or a revenue management/cycle professional staff person.
• General understanding of hospital-based outpatient charging, coding, and/or revenue capture functions.
• Knowledge of APC and OPPS reimbursement structures preferred.
• Possesses strong project management skills.
• Possesses strong interpersonal skills, with demonstrated success at communicating effectively with all levels of the organization, especially senior leadership and department heads.
• Demonstrates skilled ability and comfort with electronic medical records (EPIC preferred), and hospital billing functions
• Proficient with personal computer applications (Excel, Word, and Power Point). 
• Effective organizational skills with the ability to prioritize and manage multiple functions and responsibilities simultaneously.
• Ability to organize and work with minimum supervision at a high level of motivation and initiative while being entrepreneurial, creative and results oriented and must possess proactive orientation with a willingness to take managed risks.
• Effective verbal and written communication skills and good listening skills and the ability to interpret end users’ needs.
• Strong problem solving and investigative skills

WORKING CONDITIONS

WORK CONTEXT

• Ability to form positive, collaborative relationships with physicians, colleagues, hospital staff, patients, families, and external contacts.
• Ability to provide guidance and direction to subordinates, including performance standards and monitoring performance.
• Ability to encourage and build mutual trust, respect, and cooperation among team members.
• Ability to communicate with people outside the organization and represent the organization to the public, government, and other external sources.
• Ability to work independently or within a team structure.
• May be exposed to environmental cleaning chemicals

PHYSICAL FACTORS

• Requires Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.
• Ability to tolerate prolonged periods of sitting or standing and/or walking.
• Ability to reach reasonable distances to handle equipment.
• Good manual and finger dexterity.
• Must be able to perform the duties with or without reasonable accommodation.
• Hearing and vision must be normal or corrected to within normal range.
• Physical presence onsite is essential