Clinical Documentation Specialist

Job Description

The Clinical Documentation Specialist works independently and is responsible for performing clinical chart

reviews and pre-charting on risk adjustable patient populations. The Clinical Documentation Specialist

exercises critical thinking by applying clinical knowledge to correlate relevant diagnoses for the primary

care physician (PCP) to consider at the time of the face to face visit. The Clinical Documentation Specialist

will also be responsible for tracking and verifying all their findings.

Leads or provides education/training to clinical care and administrative support team members regarding

the clinical documentation requirements essential for risk adjustable diagnoses and their impact on

reimbursement and regulatory requirements set forth by CMS and other regulatory entities. Assists in

developing educational materials as needed.

Qualifications

Education

• High School Diploma/GED - minimum
• Bachelor's Degree Bachelor's Degree in Nursing or Health Information Management. - preferred

Experience

• 3 years Medicare risk adjustment coding & documentation required
• 2 years Experience providing training information to clinical and administrative

staff preferred

• 3 years Experience using software such as Microsoft Office including Excel and

PowerPoint to develop presentations preferred

• 1 year Exposure to risk adjustment analytics platform(s) to gain insights into

risk adjustment performance and opportunities required

Licenses and Certifications

• Valid Clinical CA license preferred (PA, NP, LVN or RN)
• Registered Health Information Administrator preferred
• AHIMA or AAPC coding credential and/or registration (One or more of the following: CDIP, CDEO, CCS, CPC, CRC) required