Clinical Documentation Specialist in Washington, DC at The GW Medical Faculty Associates.

Date Posted: 9/17/2020

Job Snapshot

  • Employee Type:
    Full-Time
  • Location:
    Penn Street Northeast
    Washington, DC
  • Job Type:
  • Experience:
    At least 5 year(s)
  • Date Posted:
    9/17/2020

Job Description

Overview

The George Washington Medical Faculty Associates is positioned to offer an exciting opportunity for a professional to join our ambulatory CDI team as we build the Outpatient CDI program. This position collaborates with MFA physicians, advanced practitioners and clinical staff to obtain complete, highest quality clinical documentation to support charge capture, reimbursement and risk adjustment. This will be accomplished by utilizing clinical knowledge and understanding of coding guidelines (ICD-10-CM, CPT and HCPCS Level II) to performing thorough chart review, provider/coder mismatch reconciliation, physician education and compliant physician querying.

Reports To: Director, Clinical Documentation Improvement

Responsibilities

  1. Conducts daily prospective/concurrent/retrospective medical chart reviews to assure accurate documentation supporting diagnosis and procedure codes - ICD-10-CM specificity, CPT, Evaluation and Management (E/M) Levels, HCCs.
  2. Analyzes clinical status of patients, current treatment plan and past medical history and identifies potential gaps in physician documentation.
  3. Formulates compliant physician query to connect gaps in documentation to support medical necessity, diagnosis and procedure coding.
  4. Collaborates with coding staff on provider/coder mismatches to ensure the medical record contains the necessary elements to support medical necessity and accurate coding.
  5. Understands professional coding and billing, risk adjusted payment methodologies, HCC assignment, OPPS reimbursement methodology and shares this knowledge with colleagues and clinical team members.
  6. Develops and delivers education to the medical staff, clinicians, and department team members on the application of coding guidelines and practices, documentation requirement, documentation improvement areas etc. using a variety of teaching methods including but not limited to: small group presentations, department meetings, physician in-services in person and remotely through the use of technology.
  7. Consistently meets quality productivity standards of record review.
  8. Identify when additional documentation is required to proactively prevent unnecessary denials using a wide rage of references (clinical payer policies, LCD/NCDs)
  9. Collaborates with clinical staff, Information Technology, and others on identifying software and template improvement opportunities.
  10. Assists with data analysis, benchmarking, trending, and presentation of audit/review findings, potential issues, and their root cause.
  11. Performs all other duties or special projects requested by CDI leadership and proactively communicates any problems that arise to maintain a smooth operation of the department.

Qualifications

Education:

  • Two (2) years of college or equivalent.
  • Working knowledge of human anatomy/physiology and disease processes through coding knowledge or education is needed.
  • Physician, Registered Nurse, Nurse Practitioner, Physician Assistant, Professional Coder Required.

License/certification:

  • Certified Clinical Documentation Specialist (CCDS) and/or Certified Clinical Documentation Specialist – Outpatient (CCDS-O) and/or Certified Professional Coder (CPC) and/or Certified Coding Specialist-Physician-based (CCS-P) preferred.
  • 1-year experience as CDS (Outpatient) or 5 years’ experience as a professional coder (CPT, E/M services) preferred.
  • Ability to complete and obtain professional coding certification (CPC/CCS-P) within 2 years
  • Certified Clinical Documentation Specialist-Outpatient (CCDS-O)  certification is voluntary but highly recommended;