Clinical Documentation Specialist



Marlton, Evesham Township, NJ, USA
Posted on Tuesday, October 3, 2023
Location: Advocare
Position: Clinical Documentation Specialist
This is a remote position but will require occasional local travel to Care Centers. Candidates must live in NJ or Eastern PA.
About US: Advocare, LLC is a partnership of the top doctors in New Jersey and Pennsylvania, including pediatricians, family practice and specialists. As part of the team, you’ll work side-by-side with forward-thinking professionals who strive to provide the highest quality medical care by meeting and exceeding standards for clinical outcomes while delivering exceptional patient service in an evolving healthcare environment.
Summary/Objective: The Clinical Documentation Specialist (CDS) will work in collaboration with all care centers staff (providers, nurses, MA, billers, etc..) to ensure accuracy, consistency, completeness, and the quality of documentation to support the accurate reporting of clinical care to our payers. The CDS will perform extensive chart reviews and coding reviews to ensure that the clinical documentation appropriately describes the patient’s severity of conditions, complexity of care, and appropriate coding to indicate as much. This role will utilize critical thinking, knowledge of medications, and disease process to analyze patient charts for missing information in the clinical documentation and initiate appropriate modifications with providers, and staff as appropriate. The CDS will communicate and educate providers and staff frequently on accurate and effective clinical documentation, ensuring high quality documentation.

Essential Functions:

  • Provide ongoing education and training related to HCC coding and documentation requirements.
  • Work Collaboratively with providers and practice staff to promote the capture of clinical severity of illness to support the patient’s level of care, providing real-time conversations as appropriate.
  • Clinically monitor how the medical record documentation translates into codified data including the review of provider and other clinician documentation, lab results, diagnostic information, and treatment, and assessments.
  • Communicates frequently with providers and staff verbally or in writing, on missing, unclear, or conflicting medical record documentation in person and via virtual methods.
  • Gathers and analyzes documentation for opportunities to develop and implement documentation and coding performance improvement.
  • Develop education strategies to promote complete and accurate clinical documentation and correct negative trends.
  • Demonstrates an understanding of current Quality Measure Initiatives including Value Based, Pay for Performance, and Readmission criteria.
  • Encourage and facilitate modification to clinical documentation supporting the clinical picture/level of severity of all patients.
  • Provide accurate and timely chart review to ensure the integrity of the documentation resulting in accurate diagnosis and procedure classification used for reimbursement and quality metrics.
  • Work with coding professionals to ensure accuracy of diagnostic and procedure data and completeness of supporting documentation to determine appropriate coding is assigned.

Required Competencies (Knowledge, Skills and Abilities):

  • Excellent written, verbal and listening abilities. Communicate appropriately and clearly to staff and providers.
  • Ability to manage conflict, stress and multiple simultaneous work demands in an effective and professional manner.
  • Ability to work well independently, while collaborating with other team members. Serves as a clinical resource person to staff.
  • Ability and willingness to self-motivate, to prioritize and change processes to improve effectiveness and efficiency. Adapts to changing patient or organizational priorities.
  • Ability to make independent decisions in accordance with established policies and procedures. Decisions and problem solving require a combination of analysis, evaluation, and interpretive thinking.
  • Knowledge of and appreciation for cultural diversity and low literacy issues in care provision.
  • Exceptional problem-solving and critical thinking skills.
  • Proven ability to translate current knowledge into practice.
  • Computer literacy, including, by not limited to, data entry, retrieval, and report generation.
  • Extensive knowledge of ICD-10, CPT, and CPT ll code guidelines

Required Education and Experience:

  • RN or LPN and two years minimum experience as a documentation specialist (or) equivalent in health related field with CCS or CCDS certified (or) Associate degree with CCS or CCDS

Preferred Education and Experience:

  • Bachelor’s or Master’s degree in nursing or health related field
  • Current unrestricted New Jersey and/or PA State RN license required; other states as necessary
  • 3-5 years as a Clinical Documentation Improvement Specialist,
  • 5 years of adult acute care experience in med/surg, critical care, emergency, or PACU,
  • 2 years of ambulatory primary care coding experience.
  • Strong problem-solving skills
  • Strong clinical judgement
  • Able to analyze problems and deploy strategies to improve performance in collaboration with Physicians, billers, staff, and leadership.
  • Strong working knowledge of Excel and relational databases
  • Strong interpersonal and communication skills with team members
  • Clinical Documentation Improvement Practitioner (CDIP) or
  • Certified Clinical Documentation Specialist (CCDS)
  • RN with Certified Coding Specialist (CCS)
Please note this position is posted on behalf of our partner practices. This individual will be working at the specific practice that is mentioned in the above details and will not be a direct employee of Aledade, Inc. so will therefore not be eligible for the benefits available to Aledade employees.