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Outpatient CDI Specialist I – Coder

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Outpatient CDI Specialist I – Coder


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CDS)-I position uses their coding knowledge and understanding of ICD-10 coding guidelines and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record using a concurrent and/or retrospective review process. Works collaboratively with CDS-II and CDS-III nurses to ensure that the clinical information within the medical record is accurately coded and supported with the provider’s documentation during the time of the visit. This includes accurate documentation to support the capture or Hierarchical Condition Categories (HCC), Risk Adjustment Factors (RAF), along with ICD-10-CM specificity and medical necessity of ambulatory visits. Participates in ongoing documentation improvement initiatives, including formal and informal education provided to the outpatient providers by the CDI team.


The CDS-I is viewed as the position that assists with risk adjustment coding/capture and will utilize their coding knowledge for conducting HCC capture and assist in identifying opportunities for improving the quality of the outpatient


REPORTING STRUCTURE: Supervision Received: Reports directly to the CDI Manager. Supervision Exercised: Acts as a coding expect and answers complex coding questions. Serves as a resource to other department staff. Directly Reporting: None Indirectly Reporting: None


***Requires the ability to work both remotely and on-site in the ambulatory clinics. • Must have a valid driver’s license and be able to travel to ambulatory clinics, as needed to perform provider education and shadow clinic workflows.


Education or equivalency: • Required: Associate degree in Health Information Technology (HIT) or equivalent combination of training and exp in lieu of HIT degree. Experience: • Required: 3 years’ experience with HCC Coding. • Required: Must have knowledge with coding Medicare Annual Wellness Visits and HCC reporting guidelines. • Required: Computer proficiency including MS Windows, MS Office, and internet • Preferred: Value based reporting Specialized training: • Required: The ability to pass a coding exam prior to hire • Required: Experience with Electronic Health Record, Encoder and Microsoft office software • Preferred: EPIC and 3M Encoder Software Systems. Certification/licensure: • Required: RHIA/RHIT, CCS, CCS-P, COC, or CPC. • Required: Certified Risk Adjustment Coder Certification (CRC) within twelve (12) months. • Required: Valid driver’s license. • Preferred: CCDS-O within thirty-six (36) months

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