Clinical Documentation Advisor

Overview

Assumes responsibility for regulatory coding and documentation audit and education activities with providers, clinical and ancillary staff.

Responsibilities

Performs audit and education duties, acts as primary resource to clinical sections on regulatory coding and related documentation rules and regulation.

Provides for numerous regulatory coding and documentation education aspects, including developing the Annual Education Plan and coordinating and coding education activities in assigned departments, ranging from routine record reviews to ongoing daily education activities, and conducting orientation for new provider staff.

Acts as primary advisor on charge capture tools in eD-H, and regarding development of documentation tools in eD-H.

Identifies trends through data analysis or chart review, reviewing existing policy for accuracy and developing new policies as necessary.

Applies mandated regulatory, documentation and coding guidelines to documentation, including demonstrated proficiency with all areas of CPT, ICD-10 and HCPCS coding. E/M code assignment, auditing and education.

Identifies key issues and is responsible for sharing pertinent information with the clinical sections and management to ensure accurate revenue capture and elevates regulatory concerns to management.

Ensures regulatory compliance activities are reported to the Compliance Office on a quarterly basis.

Performs other duties as required or assigned.

Qualifications

• Associates degree in a related field or equivalent with 5 years recent coding experience required.
• A background in a multi-specialty coding setting preferred.
• HCC Risk Coding background a plus.
• Strong organizational and analytical skills with the ability to effectively communicate (both orally and in writing) with all levels of staff.
• Attention to detail essential.

Required Licensure/Certifications

• Certified Professional Coder (CPC), Certified Professional Coder–Hospital (CPC-H) or Certified Coding Specialist – Physician Based (CCS-P) certification required.