CMD Clinical Documentation Specialist

CMD Clinical Documentation Specialist is a subject matter expert in both clinical practice and  risk adjustment. This role uses both clinical care guidelines, CMS coding guidelines, AHA coding clinics, and standards of compliance to improve the overall quality and completeness of the medical record. The CMD Clinical Documentation Specialist performs pre-visit audits of of ambulatory clinical documentation to ensure accurate reflection of patient clinical complexity to support physicians and improve on chronic condition recapture.

Major Responsibilities:

• Performs pre-visit medical record reviews including validation of problem list, identification of suspected conditions utilizing clinical protocols, and the ability to identify suspected conditions based on current medical community practices to ensure appropriate clinical documentation to support Hierarchical Condition Categories, ICD-10-CM specificity. Follows Advocate Aurora processes for performing a medical record review. Consistently meets established productivity targets for record review.
• Assists with analysis, trending, and presentation of audit/review findings, potential issues, and their root cause. Collaborates effectively throughout the organization by developing collegial relationships and communicating information effectively, and serving as a resource for interdepartmental colleagues. Communicates with other key stakeholders as needed regarding the identified documentation gaps for physician education. Communicates information effectively by responding to questions, concerns, and requests promptly.
• Stay abreast of industry knowledge to communicate any clinical, coding, or quality opportunities for education and training to related departments and providers. Active participation in team meetings and to support CRA, Coders, Auditors, Physicians, and others on specific documentation and recommendations.
• Other duties as assigned that support the unit, department, and facility meet organizational goals.

Licensure:
Nurse, Registered (RN)

Education/Experience Required:
Level of Education: Bachelor's Degree in Nursing.

Years of Experience: Minimum three years clinical experience in Internal Medicine, Family Practice, Geriatrics, or Emergency Medicine. Previous experience working in a clinical inpatient or outpatient setting. Experience performing chart audits or case management and working directly with physicians in a healthcare environment.

Knowledge, Skills & Abilities Required:

• Ability to discuss patients in an ethical manner that would reduce the potential for fraud and compliance issues. Ability to analyze clinical status of patients, current treatment plan, past medical history, and identifies potential gaps in physician documentation.
• Create patient specific documentation to support a clinical diagnosis related to abnormal findings within a patient’s medical history.
• Ability to independently establish and maintain working relationships that will be conducive to meeting department and organizational goals.
• Skilled at maintaining a professional demeanor and positive attitude.
• Ability to address sensitive information with physicians, peers, and management.
• Demonstrated knowledge of coding, billing, documentation requirements, and Centers for Medicare and Medicaid and Health and Human Services risk adjustment methodologies.
• Maintain professional affiliations for certifications that support accurate coding, documentation, and continuing education.
• Demonstrates critical thinking skills with ability to independently solve problems appropriately using knowledge, and current policies/procedures/guidelines and regulations.
• Ability to effectively articulate trends, opportunities, compliance issues, and education.
• Strong knowledge of Office products. Ability to learn new technology and systems as needed to perform job functions.

License/Registration/Certification: RN License and must receive Certified Risk Adjustment Coder (CRC) within 3 years of employment.

Physical Requirements and Working Conditions:



This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.