Job Description Summary

The Outpatient CDI Specialist is a hybrid role that combines the expertise of clinical documentation improvement (CDI) and outpatient Hierarchical Condition Category (HCC) coding. This position will report to the Outpatient CDI supervisor and will focus on improving the accuracy, quality, and completeness of clinical documentation in outpatient medical records while ensuring compliance with coding guidelines. The specialist will work collaboratively with providers, coding teams, and other healthcare professionals to facilitate accurate coding, improve risk capture, and optimize reimbursement while reflecting the true severity of illness and care provided.

Entity

Medical University Hospital Authority (MUHA)

Worker Type

Employee

Worker Sub-Type​

Regular

Cost Center

CC001109 SYS - Corp Quality And Safety

Pay Rate Type

Salary

Pay Grade

Health-27

Scheduled Weekly Hours

40

Work Shift

Job Description

The Outpatient CDI Specialist is a hybrid role that combines the expertise of clinical documentation improvement (CDI) and outpatient Hierarchical Condition Category (HCC) coding. This position will report to the Outpatient CDI supervisor and will focus on improving the accuracy, quality, and completeness of clinical documentation in outpatient medical records while ensuring compliance with coding guidelines. The specialist will work collaboratively with providers, coding teams, and other healthcare professionals to facilitate accurate coding, improve risk capture, and optimize reimbursement while reflecting the true severity of illness and care provided.

Minimum Qualifications

Education - High School Diploma or equivalent; associate or bachelor’s degree in nursing required.

Experience:

• Registered Nurse (RN) with at least 3 or more years’ experience either in the clinical field (RN), CDI field, (CCDS, CDIP) or coding (RHIA, RHIT, CPC, CRC, CCS) required.
• 1 or more years’ experience in HCC/Risk Adjustment preferred.
• Minimum of 3 years of experience in clinical documentation improvement, outpatient Hierarchical Condition Category (HCC), or a combination of both, preferred.
• Experience in an outpatient or acute care setting required.
• Ability to work independently, be resourceful, and possess strong organizational skills.
• Ability to communicate effectively to physicians and other clinical staff; be courteous and professional.

Certifications:

• Active certification from one of the following:

AAPC (Certified Professional Coder - CPC, or Certified Documentation Expert – Outpatient CDEO)

AHIMA (Certified Coding Specialist – CCS or Certified Documentation Improvement Practitioner – CDIP)

ACDIS (Certified Clinical Documentation Specialist - CCDS or CCDS-O)

• Candidates without a certification must obtain one within the first year of employment.
• Proficiency in ICD-10-CM, CPT, and E/M coding guidelines.

Key Responsibilities:

Clinical Documentation Improvement (50%):

• 1. Conduct concurrent reviews of medical records to ensure clinical documentation captures the full scope of patient severity, risk of mortality, and medical necessity for outpatient services.
• 2. Collaborate with physicians, nurse practitioners, case managers, and coders to identify opportunities for improving documentation of diagnoses, procedures, and medical necessity.
• 3. Query providers in a compliant and clear manner to address documentation gaps, ambiguities, or discrepancies to support accurate coding and billing.
• 4. Educate providers and clinical staff on best practices for documentation to improve outpatient encounter accuracy and quality.

Outpatient HCC Coding (25%):

• 5. Accurately assign ICD-10-CM and CPT codes for outpatient encounters, including clinical visits, emergency department visits, ambulatory surgeries, laboratory services, and observation care.
• 6. Abstract data and input into electronic medical record systems while adhering to organizational and regulatory coding standards.
• 7. Ensure coding accuracy meets or exceeds a 95% accuracy rate, following official ICD-10-CM and CPT guidelines.
• 8. Collaborate with revenue cycle and HIM teams to address coding denials, documentation issues, and billing discrepancies.

Data Integrity and Compliance (15%):

• 9. Maintain complete confidentiality of patient information and adhere to HIPAA regulations and organizational policies.
• 10. Ensure documentation and coding practices meet compliance standards for regulatory and payer requirements.
• 11. Perform audits and provide feedback to improve documentation and coding practices within outpatient settings.

Collaboration and Education (10%):

• 12. Act as a liaison between clinical providers and HIM to bridge the gap between documentation and coding requirements.
• 13. Provide training and educational sessions for providers on coding and documentation standards, focusing on outpatient services.
• 14. Participate in ongoing education and stay current with changes in coding guidelines, CDI practices, and healthcare regulations.

Additional Job Description

Bachelor’s degree in Nursing from an accredited school of nursing and a minimum of five years clinical nursing experience required. Strong clinical experience and critical thinking skills required. Extensive knowledge of patient care, and knowledge of clinical measurement tools and clinical outcomes; ability to establish cooperative working relationship with diverse groups and individuals, medical staff and other health care disciplines; program and database development a plus.

**Licensure a registered nurse by the South Carolina Board of Nursing or compact state.

**Current American Heart Association (AHA) Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification is required

If you like working with energetic enthusiastic individuals, you will enjoy your career with us!

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

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