Clinical Document Specialist-Non Certified

Staff Position Description

Position Title: Non-Certified Ambulatory Clinical Documentation Specialist

Position Code: Spc Clin Doc -8125

Department: Health Information Management

Safety Sensitive: YES

Reports to: HIM Director

Exempt Status: NO

All KHI employees are expected to perform their respective tasks and duties in such a way that supports KHI’s vision of providing the region’s best clinical care and patient service through an environment that fosters respect for others and pride in performance.

The Ambulatory Clinical Documentation Specialist (CDS) assumes leadership for the accuracy of clinical documentation to support physician billing. The CDS provides education and training of staff on clinical documentation/coding guidelines in accordance with the Medical Group and/or hospital policies and procedures. The CDS will be responsible for maintaining and completing a scheduled program of internal clinical encounter audits (pre or post visit) and education in-services to assist in documentation of provider’s accurate and complete medical decision making.

Program outcomes will be measured through accurate capture of Hierarchical Condition Categories ("HCCs") and support for provider Evaluation and Management (E/M) levels. CDS role will identify offices/providers with learning opportunities and develop the associated education and root‑cause correction.

• Performs pre‑visit reviews to identify previously documented and billed HCCs and identifies additional HCCs or other relevant diagnoses to reflect patient complexity more accurately.
• Completes retrospective review schedule for internal and ongoing E/M assignment audits.
• Develops and maintains a systematic education schedule and approach for physicians in the clinic/office setting.
• Queries the medical staff and other caregivers as necessary via written/verbal communication to obtain accurate and complete documentation.
• Uses performance and outcome data to identify high‑priority providers.
• Creates specialty‑specific education on relevant topics as identified in data analytics and from clinical encounter reviews.
• Delivers education and communicates importance of complete documentation and key concepts during regular physician meetings or on an individual basis, as needed.
• Upholds working knowledge and stays current on latest CMS and industry guidelines, with specific understanding of E/M assignment criteria and HCCs and implications for documentation.
• Identifies need to clarify documentation in records, and utilizes strong communication skills with all healthcare professionals, utilizing appropriate tools to capture needed documentation.
• Provides excellent customer service and adheres to the Behavioral Expectations Agreement.
• Demonstrates creativity and enthusiasm while pursuing the goals of the department and the organization.
• Maintains the ability to be flexible and prioritizes daily responsibilities.
• Works collaboratively with the healthcare team to facilitate documentation within the medical record that supports patient’s severity of illness and risk of mortality.
• Able to identify areas of focus through report analysis. Serves as a resource to providers and administration.
• Maintains complete confidentiality of patient information, in addition to hospital and individual provider practice pattern data.
• Provides information and in‑services as necessary to providers and ancillary staff.
• Performs other duties as assigned.

Education

Non‑Clinical:

• High School diploma or GED equivalent.
• Completion of AHIMA certified coding program.

Clinical: RN:
Associates or bachelor’s degree in nursing

Certification

Non‑Clinical: RHIA, RHIT, CCS, CPC, CRC, or COC

Clinical: RHIA, RHIT, CCS, CPC, CRC, or COC

Licensure

Clinical:
Current and valid AZ RN licensure required if not currently holding a current coding certification.

Experience: Five or more years of clinical experience in a Provider Practice or Multispecialty Group Practice setting or provider office coding experience.

Skills and Knowledge

• Knowledge of care delivery documentation systems and related medical record documents.
• Extensive clinical knowledge and understanding of…