Outpatient Documentation Specialist I

Essential Job Responsibilities/Expectations

1.Job responsibilities include those listed in competencies document.

2.Maintains a professional image and exhibits excellent customer relations to patients, visitors, physicians, and co-workers in accordance with our Service Excellence Standards and Core Values.

3.Reviews clinical documentation of outpatient visits in advance of and/or within 24-48 hours of service; works collaboratively with physicians, nurses, and ancillary providers to accurately represent EMR documentation of the patient's state, including but not limited to signs, symptoms, diagnoses, disease process, treatment plans, response to treatment, and gaps in care. Identifies opportunities to improve documentation in the EMR.

4.Identifies factors influencing the complexity of the patient's diagnosis and treatment plan; works collaboratively with physicians to improve the quality of outpatient clinical record documentation

5.Under supervision of OP CDI Specialist II, provides ongoing education regarding documentation requirements for optimal data integrity, reliability, and clinical coding

6.Review and clarify clinical issues with HIM/coding staff to assist in the assignment of ICD-10, HCC and CPT codes

7.Assists with Quality Management, Risk Adjustment/HCC, HEDIS, CIN initiatives and other population health initiatives to ensure accuracy of medical record data supports programs

8.Performs concurrent, prospective and retrospective evaluation and assimilation of the medical record along with communication with physicians and other clinicians, the CDS will be responsible for achieving improved documentation results for the organization

9.Maintains current knowledge of CMS, state rules and regulations; ICD-10, HCC coding, CPT coding, Risk Adjustment, and HEDIS/Quality measures; as well as the health system's coding and billing policies to ensure compliance and accuracy

10. Seeks to establish and strengthen interdepartmental relationships and efficiencies

11. Demonstrates effective and efficient time management skills. Assesses workflow, forms, and policies regularly and recommends changes as appropriate

12. Other duties as assigned

Job Requirements

Qualifications /Training:

2 or more years' experience either in the clinical field, CDI field, (CCDS, CDIP) or coding (CPC, CCS)

Knowledge of ICD-10, CPT and HCC coding guidelines

Licenses/Certifications/Registrations/Education:

Degree in Nursing from an accredited school or equivalent related degree in allied health field

Must obtain Certified Professional Coder (CPC) or Certified Risk Adjustment Coder (CRC), Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP) within two years of hire.

Physical Requirements: Refer to Occupational Risk Assessment

Founded in 1906, McLeod Health is a locally owned and managed, not for profit organization supported by the strength of more than 900 members on its medical staff and more than 2,900 licensed nurses. McLeod Health is also composed of approximately 15,000 team members and more than 90 physician practices throughout its 18-county service area.

With seven hospitals, McLeod Health operates three Health and Fitness Centers, a Sports Medicine and Outpatient Rehabilitation Center, Hospice and Home Health Services. The system currently has 988 licensed beds, including Hospice and Behavioral Health. The hospitals within McLeod Health include: McLeod Regional Medical Center, McLeod Health Dillon, McLeod Health Loris, McLeod Health Seacoast, McLeod Health Cheraw, McLeod Health Clarendon and McLeod Behavioral Health.

If you would enjoy working in a dynamic environment and are looking for an opportunity to become part of a stellar team of professionals, we invite you to apply online today. We are an equal opportunity employer.