Clinical Document Specialist Ambulatory Details

Clinical Document Specialist Ambulatory

Novant Health - Winston-Salem, NC

Employment Type : Full-Time

Overview: The Ambulatory Clinical Documentation Specialist (CDS) core functions include assessing, planning and implementing individual, specific education to clinicians, validating payer contract performance around HCC capture and recapture, and participating in the annual CMS Quality Payment Program reporting process.
The Ambulatory CDS develops individual specific education for clinicians regarding Risk Adjustment methodology (impact of Risk Adjustment Factor (RAF) and Hierarchical Condition Category (HCC)), coding and documentation guidelines and requirements as well as service line specific requirements, to clinicians. Clinicians include physicians, APPs and clinical staff. Performed via face to face encounters in small and large group settings as well as electronically. The CDS uses clinical/nursing knowledge, and understanding of coding guidelines (ICD-10-CM, CPT and HCPCS Level II) and standards of compliance to improve overall quality and completeness of clinical documentation within the patient electronic medical record (EMR). Works collaboratively with all clinicians to ensure documentation is accurate, complete and compliant with coding guidelines and requirements. Accomplished through the review of the complete patient EMR for coding and documentation specificity, formulating queries, as appropriate.
Ambulatory CDS review and validate specific payer patient lists on an ongoing basis, utilizing clinical and coding knowledge, to maximize payer contract benchmarks for shared savings around HCC capture and recapture rates. Also identify opportunities for provider education to share with the CDI team.
The Ambulatory CDS participates in annual Quality Payment Program data extraction for submission to the Center for Medicare/Medicaid Services (CMS). Must participate in multiple measure data extractions as needed for timely submission of data reporting to CMS. Ability to identify areas for measure improvement to report out trends to leadership.Qualifications:

• Education: High School Diploma Required. Associate's Degree Nursing or related field Preferred. BSN/BS in a related field Preferred.
• Experience: Five years of nursing experience; one year of experience in care of targeted patient population; experience in a broad range of clinical situations/settings. Required
• Licensure/Certification: Current RN licensure in the State of NC or compact state licensure Required. CPC (required within two years of hire) Preferred. CRS, CCDS-O Preferred.
• Additional Skills Required: Ability to successfully complete generic and department-specific skills validation and competency testing. Ability to complete and obtain professional coding certification (CPC) within 2 years. Completion of Risk Adjustment Coding Certification (CRC) and Certified Clinical Documentation Specialist-Outpatient (CCDS-O) is voluntary but highly recommended. Strong interpersonal communication (verbal, non-verbal and listening) skills; experience in developing and presenting educational material; ability to effectively speak before potentially large audiences; ability to write effectively; competent computer skills including navigation of word processing, spreadsheets and presentation software (working knowledge of Microsoft Office products); analytical skills; work in a continually changing work environment; needs to be self-motivated, self-directed and able to work independently with minimal supervision; able to work in a collaborative team environment; well organized and detail oriented; ability to travel/drive to multiple locations/facilities as needed.
• Additional Skills Preferred: Familiarity with EMR, specifically Epic, SharePoint and Sharedrive.

Responsibilities: It is the responsibility of every Novant Health team member to deliver the most remarkable patient experience in every dimension, every time.

• Our team members are part of an environment that fosters team work, team member engagement and community involvement.
• The successful team member has a commitment to leveraging diversity and inclusion in support of quality care.
• All Novant Health team members are responsible for fostering a safe patient environment driven by the principles of "First Do No Harm".