[Hiring] Outpatient Clinical Documentation Specialist @Altru Health System

Role Description

The Outpatient Clinical Documentation Specialist is responsible for activities which improve the accuracy of facility outpatient clinical documentation and charging, including education with the clinical departments and root cause correction to support accurate charging and coding in compliance with Hospital/Health System policies. The Clinical Documentation Specialist assists clinical areas to effectively document services and understand the relationship of documentation, medical necessity, and charging for the services provided in accordance with Hospital/Health System policies and procedures.

• Conducts regular chart reviews of assigned clinical departments to regularly review the documentation and charge accuracy and to integrate into educational sessions with the clinical departments and medical staff.
• Performs shadowing and coaching with key stakeholders in the clinical departments to facilitate adoption of best practices and improve documentation and charging accuracy.
• Takes ownership and initiative to build upon documentation and charge capture processes for identified areas of opportunity.
• Provides reporting and feedback to the clinical departments based on claim accuracy and chart reviews to encourage greater understanding and ownership of documentation and charge accuracy.
• Performs review of accounts identified as potentially missing charges and conducts additional research to help resolve the areas of opportunity and identify the root cause of the issues causing the missed charges.
• Coordinates with clinical departments as well as Coding, PFS, CDM, Finance, and others to review and correct claims and identify and resolve root cause issues.
• Performs analysis of patient clinical and billing data to identify documentation, coding, and charging opportunities, summarizes data, and prepares summary materials for discussion with clinical and/or finance teams.
• Fosters teamwork and utilizes strong team-building measures.
• Develops and maintains project plans and project tracking, including documentation of project meetings and project issues lists.
• Maintains current knowledge of applicable regulatory standards, which may impact the utilization of processes and systems.
• Works with finance to track revenue indicators and corresponding action plans.
• Conducts auditing and monitoring of assigned areas.
• Maintains strict confidentiality of all patient, employee, and physician information according to HIPAA guidelines.
• Performs other duties as assigned or needed to meet the needs of the department/organization.

Qualifications

• Registered Nurse | North Dakota Board of Nursing (NDBON) or Compact State Agreement | Prior to Start Date | HR Primary Sources
• Must hold an unencumbered nursing license prior to start.
• Required: A minimum of 2 years Related Experience.

Requirements

• This position requires proficiency in reading, writing, and speaking English to ensure effective communication in the workplace and with patients, families, and team members.

Physical Demands

• Sit: Frequently (34-66%)
• Stand: Occasionally (5-33%)
• Walk: Occasionally (5-33%)
• Stoop/Bend: Rarely (1-4%)
• Reach: Frequently (34-66%)
• Crawl: Not Applicable
• Squat/Crouch/Kneel: Rarely (1-4%)
• Twist: Occasionally (5-33%)
• Handle/Finger/Feel: Continuously (67-100%)
• See: Continuously (67-100%)
• Hear: Continuously (67-100%)

Weight Demands

• Lift - Floor to Waist Level: Sedentary (<10 pounds)
• Carry: Sedentary (<10 pounds)
• Push/Pull: Sedentary (<10 pounds)
• Slide/Transfer: Not Applicable

Working Conditions

• Indoor: Continuously (67-100%)
• Outdoor: Not Applicable
• Extreme Temperature: Not Applicable

Driving Requirement

• Infrequent Driver

Benefits

• Comprehensive benefits package for full- and part-time employees.
• Health plan and 401(k) retirement plan.
• Dental plan.
• Vision plan.
• Life and disability insurance.
• Education assistance.
• Paid time off (PTO).