Lead, Clinical Documentation Excellence Specialist

1823

Remote?: 1

Highlights (Bonus, shift, relocation, info for job):

Job Summary

 

The Lead, Clinical Documentation Excellence Specialist (CDES). In this pivotal role, you will oversee clinical documentation efforts, mentor a team of specialists, and collaborate with providers to enhance documentation quality and ICD-10 coding accuracy. Your leadership will drive improvements in clinical documentation practices, support organizational goals, and ensure accurate representation of patient care and complexity.

 

Duties and Responsibilities

 

Primary Responsibilities

• Team Leadership and Mentorship:
• Provide mentorship, training, and oversight to the Clinical Documentation Excellence (CDE) specialist team, including conducting regular overreads, offering feedback, and promoting best practices.
• Act as a resource for the team by addressing complex documentation or coding scenarios and ensuring consistency in reviews.
• Assist in onboarding new CDE specialists, including developing training materials and facilitating initial education sessions.
• Clinical Documentation Program Development:
• Design and implement strategies to enhance documentation accuracy, ICD-10 coding specificity, and risk adjustment outcomes.
• Collaborate with leadership to define key performance indicators (KPIs) for the CDE program and regularly monitor progress.
• Drive initiatives to align documentation practices with organizational goals, such as risk adjustment optimization and quality metric performance.
• Provider Collaboration and Education:
• Partner with providers to improve clinical documentation practices, providing targeted education on coding specificity, risk adjustment, and compliance standards.
• Conduct provider-focused training sessions to address common documentation challenges and share feedback trends.
• Documentation Review and Query Management:
• Conduct timely and thorough outpatient documentation reviews to identify gaps in clinical accuracy and coding specificity.
• Develop high-quality queries to clarify documentation, ensuring alignment with AHIMA/ACDIS standards and payer requirements.
• Monitor query response trends and provide recommendations for improvement.
• Program Oversight and Reporting:
• Create and deliver regular performance reports to leadership, summarizing key metrics such as query response rates, documentation improvement trends, and coding accuracy.
• Collaborate with the Quality and Risk Adjustment teams to ensure alignment of documentation efforts with value-based care goals.
• Participate in interdisciplinary team meetings, contributing insights on clinical documentation improvement strategies.
• Technology and Process Improvement:
• Leverage EMR tools to streamline documentation review workflows and identify automation opportunities.
• Propose enhancements to existing documentation processes and workflows to improve efficiency and reduce provider burden.
• Stay informed on EHR upgrades, payer requirements, and regulatory changes, and incorporate updates into team workflows.

 

Minimum Qualifications

 

Required Qualifications:

• Minimum of 5 years of combined, or equivalent, experience as a clinical RN, Foreign Medical Graduate with CDI certification, outpatient certified medical coder with CDI certification.
• Associates or Bachelor’s degree in a health science or related field of study
• Proven experience in Clinical Documentation Improvement.
• Demonstrated ability to build trusted relationships with medical and/or behavioral health providers.
• Ability to work independently, self-motivate, and adapt to change.
• Proficiency working in a Microsoft environment, including Microsoft Word, Excel, PowerPoint, Outlook, and Electronic Medical Records.

Preferred Qualifications:

• Experience applying risk adjustment concepts in CDI reviews.
• CCDS, CDIP, CDEO, or CCS certification.
• Familiarity with eClinicalWorks or similar EHR platforms.
• Eagerness to stay informed about healthcare reform and coding regulations, incorporating changes into chart review and educational responsibilities.

Licensure:

• Not required to maintain an active RN/Medical Assistant license

 

Working conditions

 

This job operates in a professional office environment.  This role routinely uses general office equipment. 

 

Physical requirements

 

• Ability to communicate clearly and exchange accurate information constantly.
• Ability to remain stationary for long periods of time.
• Constantly operates computer, keyboard, copy and fax machine, phone, and other general office equipment.

• Ability to occasionally move objects up to 20 lbs.

 

Direct reports

None.

Why Work at AbsoluteCare?

At AbsoluteCare, we serve the most vulnerable individuals in America. These are our neighbors, people who are at higher risk for disease or who have multiple, complex, chronic illnesses. Often, they deal with an unequal healthcare system and wind up seeking basic care from emergency rooms. We take these patients out of those spaces and turn them into members: people who are entitled to some of the best, most focused care this country has to offer. 

We call this “care beyond medicine.” We have turned the doctor’s office into a comprehensive care center. Here, we surround our members with a core care team of doctors, nurses, social workers, and medical assistants who have the time and skills to get to know our members’ needs. We make the most important services available to our members under one roof. This includes a pharmacy, X-rays, a blood lab, nutrition services, urgent care, and much more.

We don’t stop at our four walls. We engage members in the communities where we all live to find the people who need us most. Through these community care teams, we remove the barriers to healthcare that so many people face daily. And it works. 

Our unique care is guided by our core values of accountability, caring, trust, and teamwork. We call it ACT².

AbsoluteCare, Inc. provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, age, disability, genetics, protected Veteran status, or any other characteristic protected by law or policy.

EEO Employer Verbiage: AbsoluteCare, Inc. provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, age, disability, genetics, protected Veteran status, or any other characteristic protected by law or policy.