Clinical Doc Spec - Outpatient

Overview

The Outpatient Clinical Documentation (CDS) Specialist is responsible for ensuring the accuracy, specificity, and compliance of clinical documentation in the ambulatory setting, with a strong focus on risk adjustment and HCC capture. This role reports to Population Health and collaborates with Augusta Medical Group (AMG) providers to validate diagnoses, improve documentation quality, and enhance outpatient workflows. The Outpatient CDS Specialist focuses on ambulatory documentation, outpatient coding guidelines, and clinical decision support tools to ensure documentation reflects patient complexity and supports value-based care initiatives.

• Validate diagnoses and improve documentation quality in the ambulatory setting.
• Support outpatient workflows and ensure documentation aligns with ambulatory coding guidelines.
• Leverage clinical decision support tools to accurately reflect patient complexity and support value-based care initiatives.
• Collaborate with AMG providers and Population Health to optimize documentation processes and outcomes.

• Bachelor’s in nursing or equivalent experience
• Licensed Registered Nurse in Virginia
• Coding Certification with 6 months of hire if not already certified
• Two (2) years of clinical nursing experience
• Certification in both outpatient coding and HCC coding preferred
• Experience with ambulatory coding and documentation preferred
• Teaching/Education experience preferred

• Knowledge of health systems operations, health policy, and/or health care contracting
• Knowledge of population health programs and concepts
• Strong clinical judgment and analytical skills with high attention to detail and strong compliance mindset
• Advanced written and verbal communication skills with the ability to engage with providers
• A high degree of professionalism and competency in dealing with a variety of individuals
• Ability to teach complex concepts and maintain collaborative relationships
• Ability to independently organize and prioritize work
• Ability to interpret clinical data and translate it into actionable documentation guidance
• Ability to deploy appropriate data sources, analysis methods, and effective communication of analytical results
• Articulates and presents data, information, and ideas in a clear and concise manner
• Creates an environment that encourages diverse opinions, recognizes differences and incorporates into process and services

• Retirement savings helping you to plan for your future
• Free onsite parking
• 24/7 armed security to ensure your safety
• Tuition reimbursement
• Onsite child care
• Augusta Health Fitness Reimbursement Program
• Individualized orientation with dedicated preceptor
• Onsite credit union
• Employee discounts including the cafeteria, gift shop, pharmacy, and movie tickets

Augusta Health is a mission-driven, independent, nonprofit, community health system located in Fishersville, Virginia in Virginia’s scenic Shenandoah Valley. Augusta Health offers a full continuum of inpatient and outpatient services, including Augusta Medical Center, a 255-bed inpatient facility, and Augusta Medical Group, which comprises 40 practice locations and four urgent care locations.

Augusta Health recruits, hires and promotes qualified candidates for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran or military discharge status, and family medical or genetic information.