Brockton Hospital Clinical Documentation Integrity Specialist- Ambulatory in Brockton, Massachusetts
This position will be responsible for utilizing clinical/nursing knowledge, and understanding of current CMS coding guidelines, conventions and AHA coding clinics to improve the overall quality and completeness of the patient medical record. Through a multidisciplinary team process, the Ambulatory CDI Specialist performs pre-visit and retrospective reviews of ambulatory clinical documentation to ensure accurate depiction of the true complexity of the patient. This includes compliant documentation to support the capture or Hierarchical Condition Categories (HCC), ICD-10-CM accuracy and specificity, and medical necessity. S/he will work collaboratively with ambulatory physicians and advanced practice providers to communicate opportunities and educate members of the patient care team regarding documentation guidelines, coding requirements and service-line specific requirements. S/he will also communicate with coders and compliance specialists regarding documentation clarification and accurate coding, as needed. Participates in select committees and provides education programs as necessary.
Registered Nurse with Bachelor’s Degree preferred and current Massachusetts license without limitations. Ambulatory nursing or clinical experience preferred. Experience with Medicare risk adjustment, Hierarchical Condition Categories, coding, billing, auditing preferred. Graduate from an accredited Health Information Management program (AS or BS/BA), Current Certification in Clinical Documentation Improvement (CDIP, CCDS, CCDS-O or CDEO) highly preferred or appropriate certification within 2 years of employment. Seasoned coder with strong clinical knowledge and 2 years minimum coding experience (inpatient/outpatient).