2+ years acute care hospital clinical /coding experience
3+ years outpatient clinical/coding Excellent verbal written in organizational skills
Bachelors Degree or combination of education and experience
445 Grant Avenue, San Francisco, CA 94108
The Clinical Document Improvement Specialist – (CDS) is responsible for providing CDI program oversight and day to day CDI implementation of processes related to the review of the clinical documentation for inpatient and outpatient medical records of CCHP members and other clients with a focus on HCCs and the support of documentation that supports the reporting of inpatient and outpatient quality indicators; medical necessity of services provided; develops and implements the appropriate policies and procedures in order to assure technical accuracy, specificity, and completeness of provider clinical documentation; and ensures that the documentation explicitly identifies all of the clinical findings and conditions present which were evaluated assessed and treated at the time of the service.
The CDS collaborates with providers and other plan and healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely the clinical evaluation, treatment, decisions, and diagnoses for the patient and which accurately reflects the appropriate risk scores and quality indicators. The CDS utilizes clinical and coding expertise and implements clinical documentation improvement practices utilizing appropriate tools that support best practices and compliance with federal, state and accrediting entities and is consistent with the mission, philosophy, standards, goals and core values of CCHP.
The CDS will utilize and when appropriate improve currently available resources that assist primary care physician and other providers to document and support codes that accurately reflect the severity of illness, risk of mortality and the patient’s medical conditions: the principal diagnosis and each of the secondary diagnoses and associated complications if any in order to accurately capture the quality of care and support accurate and compliant risk scores.
This position will require the ability to provide clinical documentation improvement training and consultations with a focus on HCCs to primary care physicians and advanced practitioners that provide services on behalf of CCHP members.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Provides expert level review of outpatient and inpatient clinical records and identifies gaps in clinical documentation that require clarification for the accurate complete and compliant code assignment to ensure the documentation accurately reflects the severity of the condition and acuity and risk associated with the care
- Collaborates with the CCHP Medical Director, Health Care Management, Utilization Management, Case Management, Quality Improvement and Claims personnel in the improvement and when required development of appropriate tools to facilitate and support the accurate and complete documentation and reporting of conditions from medical
- Actively participates in the development of training materials for providers including but not limited to query/clarification templates and compliant content, PowerPoint presentations, and on/off site education guidance and
- Conducts regular follow-up communication with providers regarding existing clarifications to obtain needed documentation
- Offers expert level leadership for overall improvement in clinical documentation by providing proficient level review and assessment, and effectively articulating compliant recommendations for improvement, and the clinical and coding rationale for the recommendations.
- Actively communicates with providers at all levels, to clarify information and to communicate documentation requirements for appropriate
- Provides remote and or on-site communications and guidance in the form of compliant queries/clarifications with providers including but not limited to physicians, nurse practitioners, other licensed providers and support
- Provides onsite face-to-face educational opportunities for physician and advanced practitioners and support
- Provides complete follow through on all requests for clarification or recommendations for improvement and tracks and reports the effectiveness of those efforts.
- Leads the development and execution of physician and advance practitioner education strategies including web based tools which are designed to result in improved clinical
- Provides timely feedback to providers regarding clinical documentation opportunities for improvement and
- Ensures effective utilization of appropriate and available technologies to document all verbal, written, electronic clarification
- Utilizes only the CCHP approved clarification documents policies and procedures.
- Proactively develops a collaborative relationship with CCHP, contracted hospital(s) and physician/provider nursing clinical and Coding
- Engages responds and is accountable to the Medical Director and the CCHP Director of Health Care Management when appropriate pursuant to the established escalation process, to resolve provider issues regarding answering clarifications and participation in the clinical documentation improvement process.
- Actively engages with CCHP Health Care Management UM Care Coordination and the Quality Management teams and Compliance to continually evaluate and spearhead clinical documentation improvement
- In collaboration with Medical Director and Director of Health Care Management designs develops and implements programs to meet or exceed CCHP physician and hospital performance targets for improved risk adjustment scores and STAR ratings and other quality performance
- Presents progress and outcome reports on a regular basis and identifies gaps in performance and strategies to mitigate (monthly, quarterly and annually) to Medical Director, Committees, and as appropriate selected
- Accepts and performs other duties as
- Experienced in Clinical Documentation Improvement
- CPC, ICD-10 Certified /Proficient, American Academy of Professional Coders or equivalent
- Proficient and in compliant E&M documentation billing and coding appropriate assignment of MDS-DRGs, APR-DRGs, APCs and
- EMR proficient
- Knowledgeable in each CCHP health plan and the EOCs (Medicare Advantage, Dual Eligible, MediCal Commercial )
- Knowledgeable of CMS, MediCal, National Local and Plan determinations
- 2+ years acute care hospital clinical /coding experience
- 3+ years outpatient clinical/coding
- Excellent verbal/written communication and organizational skills
- Good working knowledge of knowledge MS Office, Word, Excel,
- Proficient in Power Point development and ability to provide physician to physician/provider presentations
- Highly skilled and knowledgeable in HCCs, risk scores and risk-based contract arrangements
- Highly skilled in documentation and appropriate assignment of CPTs, MS-DRGs, APR- DRGs, HCCs and E&M
- Knowledgeable in HEDIS, URAC and STAR; Value Based Purchasing Pay for Performance and other Alternative Payment Mechanisms
- Certification as a CCDS, CDIP, CPC, CCS /American Academy of Professional Coders or equivalent
- Able to lift up to 30 pounds
- Use proper body mechanics when handling equipment
- Standing, walking and moving 50% of the day.
In our efforts to control the spread of COVID-19 and its variants, CCHP requires that its employees be fully vaccinated as of their start date. If you require a medical or religious accommodation we will engage in the interactive process with you. Proof of vaccination will be required prior to start. If we make you an offer and you are not yet vaccinated, we will accommodate a delay in start date. CCHP may also mandate that its employees receive vaccine boosters, and all accommodation laws will be followed.