Clinical Documentation Improvement Specialist

Job Title: Clinical Documentation Improvement Specialist 

Department: Ambulatory Surgery

Hours: 40 hours per week/Shrewsbury or Medford, MA

 Reports to: VP of Ambulatory Surgery

About our Ambulatory Surgery Centers:

With a legacy deeply rooted in outpatient imaging, Shields built upon this expertise, diversifying our healthcare portfolio to include ambulatory surgical services. 35 years of success in healthcare has earned Shields Ambulatory Surgery Centers (Shields ASC) a leading position in the surgery center industry.

Through joint-venture partnerships with hospitals and providers, Shields leverages our value-based position and operational discipline to develop, execute and manage multi-specialty ambulatory care facilities. The ASC facilities are designed to maximize profitability for our partners while delivering critical patient-centered medical services in a very accessible location at an accessible price for patients. Shields ASC transforms the outpatient experience by providing a convenient alternative to hospital-based procedures that are more cost-effective for our partners and our patients.

About the Role:

The Clinical Documentation Improvement Specialist (CDS) is responsible for conducting extensive analysis of patient health records in order to ensure complete and accurate documentation, as well as identification of diagnosis codes to properly reflect the severity of patient illness. The CDS collaborates with physicians to advocate for clear and succinct documentation, reflecting the extent of patient care provided, and to ensure proper reimbursement.

•    Assists with appropriate identification of diagnoses, conditions and/or procedures that are representative of the patient's procedure and care provided to ensure patient medical charts are complete, accurate, and coded for revenue integrity

•    Utilizes advanced clinical and coding expertise to direct efforts toward the integrity of clinical documentation through the roles of reviewer, educator and consultant

•    Initiates concurrent queries to providers as supported by medical record documentation to improve the accuracy, integrity and quality of patient data, and drive improvement toward quality physician documentation within the body of the medical record

•    Collaborates closely with ASC Operations, coding, clinicians, medical staff, physicians, and medical office staff to improve documentation and importance of complete and accurate documentation

•    Performs chart audits to review for missing, unclear, or conflicting medical record documentation, and initiate queries to physicians requesting and obtaining additional documentation within the medical record before coding and billing

•    Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the medical record

•    Educates members of the patient care team regarding documentation opportunities and best practices to ensure accurate documentation in the medical record

•    Applies diplomacy and professionalism when interacting with physicians and clinicians; especially when addressing missing or conflicting medical record information

•    Investigates, evaluates, and identifies opportunities for improvement and recognizes their relative significance in the overall system

•    Provides orientation for new clinical staff regarding documentation requirements as required

•    Keeps current with concepts and practices through conferences, reference material and review of current literature

•    Maintains confidentiality of all patient information in accordance to HIPPA policies

•    Demonstrates flexibility in the face of changing work environment, adjusting work schedule accordingly

•    Meets regularly with the Administrators/Nurse Managers and Clinicians, as well as medical office staff to review all paperwork and to update them regarding new documentation requirements and ensuring revenue integrity

            About You:

•    Bachelor’s degree in Nursing or Health Informatics preferred but not required

•    3 years of clinical coding experience within a surgical setting, preferably in Ambulatory Surgery 

•    Ambulatory Surgery Coder Certification (CASCC)

•    Extensive background in medical terminology, anatomy and physiology 

•    Understanding of CCI, edis, and LMRP standards for coded charts

•    Complete knowledge of Ambulatory Surgical ICD10, CPT and HCPC codes 

•    Comprehensive knowledge of coding/billing modifiers, implants and bundling rules 

•    Ability to audit clinical documentation and coded data to validate documentation supports services rendered for reimbursement and reporting purposes

•    Excellent oral and written communication skills.

•    Organized, able to set priorities and meet deadlines.

•    Proficient computer skills 

•    Collaborative team play

•    Knowledge of pertinent Federal, State, and local laws, codes, and regulations.

NOTE: The Job Description does not encompass all work functions of this position. The incumbent will undertake tasks of lower or equivalent classification as needed, and may also engage in higher classification work for training, development, or as warranted by