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Clinical Documentation Specialist
The Clinical Document Improvement Specialist - (CDS) is responsible for providing CDI program oversight and day to day CDI implementation of processes related to the review of the clinical documentation for inpatient and outpatient medical records of CCHP members and other clients with a focus on HCCs and the support of documentation that supports the reporting of inpatient and outpatient quality indicators; the medical necessity of services provided; develops and implements the appropriate policies and procedures in order to assure technical accuracy, specificity, and completeness of provider clinical documentation; and ensures that the documentation explicitly identifies all of the clinical findings and conditions present which were evaluated assessed and treated at the time of the service.
The CDS collaborates with providers and other plan and healthcare team members to make improvements that result in accurate, comprehensive documentation that reflects completely the clinical evaluation, treatment, decisions, and diagnoses for the patient and which accurately reflects the appropriate risk scores and quality indicators. The CDS utilizes clinical and coding expertise and implements clinical documentation improvement practices utilizing appropriate tools that support best practices and compliance with federal, state, and accrediting entities and is consistent with the mission, philosophy, standards, goals, and core values of CCHP.
The CDS will utilize and when appropriate improve currently available resources that assist primary care physicians and other providers to document and support codes that accurately reflect the severity of illness, risk of mortality and the patient’s medical conditions: the principal diagnosis and each of the secondary diagnoses and associated complications if any in order to accurately capture the quality of care and support accurate and compliant risk scores.
This position will require the ability to provide clinical documentation improvement training and consultations with a focus on HCCs to primary care physicians and advanced practitioners that provide services on behalf of CCHP members
Time: Full time
Updated: 10/26/2021 4:39:16 PM