Ambulatory Clinical Documentation Specialist

Overview

The Ambulatory Fee Clinical Documentation Specialist is responsible for following ambulatory facility and clinic

processes while providing clinically based reviews of documentation to capture accurate charges for services rendered.

The Ambulatory Clinical Documentation Specialist will engage with providers to provide documentation education in

addition to providing Profee Education and training, ProFee opportunity identification and provide any additional support

to the providers as required and needed.

Responsibilities

The goal of concurrent review includes facilitation of appropriate physician documentation of care delivered to accurately reflect patient severity of illness, risk of morality and care provided.

Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care and ambulatory services.

Duties Include

Duties include of the Ambulatory Clinical Documentation Specialist:

Conduct chart reviews of the ambulatory setting daily and as requested to regularly review the

documentation and charge accuracy and to integrate into educational sessions with the Clinical

departments and medical staff

Performs review of accounts identified or requested for potential opportunity and opportunity for

provider education. Conducts additional research to help resolve the areas of opportunity and

identify the root cause of the potential missed opportunities

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

Maintains current knowledge of applicable regulatory standards, which may impact utilization of

processes and systems

Demonstrates creativity and enthusiasm while pursuing the goals of the department and the

organization

Provides education to providers and other staff as deemed appropriate

Maintains the ability to be flexible and prioritizes daily responsibilities

Attends meetings, educations sessions and trainings as scheduled

Maintains strict confidentiality of all patients, employee and physician information according to

HIPAA guidelines

All other duties as assigned for both Clinical and Ambulatory Clinical Documentation Specialist

Other Job Responsibilities Include

• Shares in organization’s vision, demonstrates its values, supports its philosophy and is sensitive
  
  

to its mission. Demonstrates knowledge of and follows departmental and hospital policies and

physician office procedures

• Seeks out opportunities for individual growth and development, including attending various
  
  

meetings, conferences, courses, seeking certifications, as required.

• Uses tact and sensitivity when communicating with patients, visitors, co-workers, and other
  
  

personnel

• Serves on department and/or institutional committees as requested
  
  

Qualifications

Education

Bachelor’s, or Associate’s Degree in Nursing or Health Information Management or related field

Minimum Work Experience  Minimum of 5 years of clinical experience in an acute care setting or of 5 years experience in coding in an acute hospital setting

Required Licenses/Certifications

RN, BSN, RHIA or RHIT credential required  Education: Minimum Associate Degree  Licensure / Certification: CCS-P, CPC, CRC, or other coding credential a. RN or LPN helpful but not required

Required Skills, Knowledge, And Abilities

• Knowledge of care delivery documentation systems and related medical record documents.
• Knowledge of age-specific needs and the elements of disease processes and related procedures.
• Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
• Excellent written and verbal communication skills.
• Excellent critical thinking skills.
• Demonstrated good nurse-physician relationships in the past and can maintain those going forward.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time-oriented environment.
• Computer literacy and familiarity with the operation of basic office equipment.
• Assertive personality traits to facilitate ongoing physician communication.
• Ability to stand, sit and walk for periods of time is required in the performance of job responsibilities.
• Working knowledge of Medicare reimbursement system and coding structures preferred, but not required.