Educator-Outpatient Clinical Documentation Integrity

J  o  b    D  e  s  c  r  i  p  t  i  o  n

          Joy                         Care                      Competence                    Respect

Position Summary

Conduct provider medical record audits, analysis of practice patterns, education and training regarding risk adjustment to ensure accurate Centers for Medicare & Medicaid Service (CMS) payment and improve quality of care. Analysis of medical risk adjustment (MRA) data to identify patterns and develop interventions at the physician and market level. The Outpatient Clinical Documentation Integrity Educator is responsible for conducting coding and billing training to physicians, coders, and other interested personnel, including developing the curriculum and training materials, and assessing competency. Will perform quality assurance reviews/audits with appropriate feedback. Monitors coding and billing regulations to assure compliance with governmental and payer regulations.

Bachelor’s degree in Nursing, Health Education, Health Information Management, Healthcare Administration, Business, or related field is required.

Graduate from an accredited and approved school of nursing accepted for licensure in the state of practice is preferred.

3 years Hierarchical Condition Category (HCC) coding experience is required. 

Incumbent must have demonstrated prior experience in an managed care environment working with providers on improving clinical documentation and coding in all aspects, to include professional fee (E&M CPT) and diagnosis (HCC Risk Adjustment). 

Certified Professional Coder (CPC), or Certified Risk Adjustment Coder (CRC) is required within 12 months of hire.

Certified Clinical Documentation Specialist-Outpatient (CCDS-O) is preferred.

Licensed as a Registered Nurse (RN) in the state of practice is preferred.

Expert knowledge of HCC Risk Adjustment and CPT Professional Fee coding in the ambulatory setting.

Working knowledge of clinical documentation alerts (BPA’s) in Epic.

Consistent demonstration for commitment to quality, customer focus, productivity, and process improvement.

Ability to work independently, with high productivity, and regularly meet deadlines.

Demonstrate excellent written and verbal communication skills conforming to all rules of punctuation, grammar, diction and professional style.

Experience in developing educational content for use in both didactic and 1:1 education with providers.

Knowledge of and experience in application of compliance regulations for CPT and HCC coding, documentation and billing in ambulatory setting.

Conduct physician and provider education and training regarding risk adjustment to help to ensure accurate CMS payment and to improve quality of care. This includes training venues such as provider offices, webinars, conference calls, email correspondence, etc.

Perform daily medical record reviews and data collection activities to identify documentation issues, quality issues and opportunities for improvement. Ensures level of service and acuity of care is accurately reflected in quality outcomes.

Partners with operations, physician advisors and other departments (to include provider relations, quality, and coding) to identify, develop, and implement successful communication and education, to engage providers and improve outcomes, processes and support HCC capture of ambulatory visits to ensure compliance of CMS risk adjustment guidelines are met.

Acts as a subject matter expertise for proper risk adjustment coding and CMS data validation.

Analyze MRA data to identify patterns and development of interventions at the provider and market level to coordinate an educational work plan for Physician Enterprise physicians and providers.

Demonstrates knowledge of documentation requirements and coding guidelines that pertain to ambulatory diagnosis coding to accurately reflect the complexity and medical necessity of the visit.

Monitors, assists and tracks the progress of the ambulatory clinical documentation program through analysis, trending, and presentation of audit/review findings, potential issues, and their root cause. Serves as a resource to physicians and administration regarding issues related to compliant documentation.

Possess the information, skill, and understanding of the work to be performed.  Actively participates in continuing education opportunities and maintains certifications, licensure as appropriate.

Reduces the risk of healthcare acquired infections through compliance with current CDC hand hygiene guidelines and facility policies including the wearing of Personal Protective Equipment (PPE), if applicable.  Utilizes standard precautions during patient contact and when handling contaminated materials.  Demonstrates compliance with National Patient Safety Goals.

Complies with all standards, policies and procedures including dress code, attendance and punctuality.  Attends required in-services and meetings and completes all mandatory competencies by deadline.  Commits to keeping all patient, student or colleague information confidential and maintains excellent interpersonal communication with the health care team colleagues.

Emphasizes a holistic approach to patient care-attending to body, mind, and spirit while upholding ethical principles with patient care and all other aspects of work.  Actively involves the patient and family in decisions about care.  Promotes quality care by participating in organizational councils/committees and/or support of related process.  Documents services provided to patients in the electronic medical record in accordance with policy and requirements. 

The purpose of this job description is to provide a summary of the major responsibilities performed by colleagues in this position. Colleagues may be requested to perform tasks other than those specifically presented in this job description.  Variances in job duties performed may exist between facilities, and colleagues may perform other related duties as assigned to meet the needs of the organization.

PHYSICAL, MENTAL AND ENVIRONMENTAL REQUIREMENTS

Physical, Mental and Environmental Requirements Category:

Administrative

Standing

X

Walking

X

Sitting

X

Lifting

X

20 lbs.

Carrying

X

20 lbs.

Pushing

X

20 lbs.

Pulling

X

20 lbs.

Climbing

X

Balancing

X

Stooping

X

Kneeling

X

Crouching

X

Crawling

X

Reaching

X

Use of Hands/Dexterity

X

Talking

X

Hearing

X

Eye/Hand/Foot Coordination

X

Extreme Cold

X

Extreme Heat

X

Humid

X

Wet

X

Noise

X

Hazards

X

Temperature Change

X

Atmospheric Conditions

X

Vibration

X

Other