Clinical Documentation Specialist I - Remote

About Our Client:

The organization operates within the healthcare sector, focusing on improving clinical documentation and coding accuracy in outpatient physician practices. It addresses challenges related to the completeness and quality of medical records, which impact patient care and coding accuracy. The organization collaborates closely with physicians, Health Information Management, and other teams to enhance documentation practices, thereby supporting better health outcomes and compliance with payer requirements.

About the Opportunity:

The CLINICAL DOCUMENTATION SPECIALIST I role is designed to improve the quality and accuracy of clinical documentation and coding in outpatient settings. This position plays a critical role in identifying documentation gaps, educating physicians, and ensuring that coding accurately reflects patient health status. The specialist acts as a liaison between clinical and coding teams, contributing to more precise health records and supporting risk adjustment and compliance efforts.

Responsibilities:

• Facilitate improvement in medical record documentation and coding accuracy.
• Review patient charts to identify documentation gaps, focusing on primary care visits.
• Conduct coding and clinical validation audits, emphasizing Hierarchical Condition Categories (HCC) coding.
• Use available data to find opportunities for enhancing outpatient coding specificity.
• Communicate and coordinate chart reviews with physician office staff.
• Analyze returned documentation alerts for accuracy.
• Review outpatient visit diagnoses and service levels before claim submission.
• Obtain clarifications from physicians to ensure complete documentation.
• Participate in data collection and performance reporting.
• Provide ongoing education to physicians on compliant documentation and coding.
• Identify training needs and conduct coaching to improve documentation quality.
• Monitor coding changes and educate practices on compliance.
• Ensure clinical documentation complies with State and Federal payer regulations.
• Perform related duties as needed.

Requirements:

• High school diploma or GED required; Associate degree or higher preferred.
• Minimum of 3 years coding experience.
• At least 1 year of HCC Risk Adjustment experience preferred.
• Clinical background in healthcare setting preferred.
• Required credentials: Certified Coding Specialist (CCS), Certified Risk Adjustment Coder (CRC), or Certified Professional Coder (CPC).
• Experience with front-end process improvement.
• Knowledge of ICD-10, CPT, and HCPCS.
• Familiarity with CMS HCC Risk Adjustment coding and data validation.
• Familiarity with APC coding.
• Proficient in Microsoft Excel.
• Strong communication, mentoring, time management, and organizational skills.
• High accuracy, efficiency, and dependability.

Pay Range and Compensation Package:

• The salary range for this role is $65,885.00 to $98,827.00 annually, depending on experience, education, and operational needs. This range does not include bonuses, differential pay, or other compensation.

Equal Opportunity Statement: Our client is an equal opportunity employer. They celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, or national origin.

Note:

RemoteHunter is a recruitment partner of this role. Please note that all employment decisions, including candidate assessment, interviews, hiring, compensation, and employment terms, are made exclusively by the hiring employer.