Full-Time
Outpatient CDI Specialist 1
Medical University of South Carolina
Health sciences university in Charleston, SC
No salary listed
No H1B Sponsorship
South Carolina, USA
Remote
Bachelor's
Category
 Medical, Clinical & Veterinary (1) |
|---|
Required Skills
Electronic Health Records (EHR)
HIPAA
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Requirements
- A bachelor's degree in nursing from an accredited school of nursing is required.
- At least three years of clinical nursing, clinical documentation improvement, coding, or combined relevant experience is required.
- An active registered nurse license from the South Carolina Board of Nursing or a compact state is required.
- Strong clinical experience and critical-thinking skills are required.
- Extensive knowledge of patient care, clinical measurement tools, and clinical outcomes is required.
- Experience in an outpatient or acute-care setting is required.
- Candidates without an approved certification must obtain one within the first year of employment.
- The ability to work independently, be resourceful, and maintain strong organizational skills is required.
- The ability to communicate effectively with physicians and other clinical staff and to maintain courteous, professional working relationships is required.
- Confidentiality of patient information and compliance with HIPAA, organizational policies, regulatory requirements, and payer requirements are required.
Responsibilities
- Conduct concurrent and retrospective reviews of medical records to ensure documentation captures patient severity, risk of mortality, and medical necessity for outpatient services.
- Collaborate with physicians, nurse practitioners, case managers, and coders to identify opportunities to improve documentation of diagnoses, procedures, and medical necessity.
- Query providers in a compliant and clear manner to address documentation gaps, ambiguities, or discrepancies and support accurate coding and billing.
- Educate providers and clinical staff on documentation best practices to improve encounter accuracy and quality.
- Assign ICD-10-CM codes accurately for outpatient encounters, including clinical visits, emergency department visits, ambulatory surgeries, laboratory services, and observation care.
- Abstract data and enter it into electronic medical record systems while following organizational and regulatory coding standards.
- Maintain at least a 95% coding accuracy rate in accordance with official ICD-10-CM guidelines.
- Act as a liaison between clinical providers and Health Information Management to connect documentation and coding requirements.
- Participate in provider education on coding and documentation standards for outpatient services.
- Complete ongoing education and remain current with changes in coding guidelines, clinical documentation improvement practices, and healthcare regulations.
Desired Qualifications
- At least one year of experience in Hierarchical Condition Category or risk adjustment is preferred.
- At least three years of experience in clinical documentation improvement, outpatient Hierarchical Condition Category, or a combination of both is preferred.
- Certification from AAPC as a Certified Professional Coder, Certified Risk Adjustment Coder, or Certified Documentation Expert—Outpatient is preferred.
- Certification from AHIMA as a Certified Coding Specialist or Certified Documentation Improvement Practitioner is preferred.
- Certification from ACDIS as a Certified Clinical Documentation Specialist or Certified Clinical Documentation Specialist—Outpatient is preferred.
- Proficiency in ICD-10-CM is preferred.
- Program and database development experience is a plus.
Medical University of South Carolina is a public academic health sciences university in Charleston, South Carolina. It offers bachelor's, master's, doctoral, and professional degrees through six colleges in dental medicine, graduate studies, health professions, medicine, nursing, and pharmacy.
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