|Employer:||McLaren Medical Group
|Required Certifications:||CDEO or CPMA or RHIT,CCDS,CCDS-O
|Required Experience:||1 to 2 years
|Preferred Experience:||3 to 4 years
1. Ensures the accuracy and completeness of clinical documentation used for reporting professional services in the ambulatory setting.
2. Improves the overall quality, integrity and completeness of the ambulatory clinical documentation by performing chart audits/reviews to verify appropriate ICD10 and CPT codes are assigned, and documentation requirement are met.
3. Conducts meetings with the providers, clinical staff and coding staff to review documentation issues and improvement opportunities.
4. Facilitates modification to the ambulatory clinical documentation to ensure appropriate reimbursement is received for the level of service rendered to all patients.
5. Educates all members of the patient care team regarding clinical documentation opportunities, changes to clinical documentation guidelines, coding and reimbursement issues, as well as performance improvement methodologies.
6. Conducts follow up reviews of ambulatory clinical documentation to ensure points of clarification have been recorded in the medical record.
7. Uses interpersonal skills to discuss clinical documentation issues and works effectively with all levels of internal personnel such as coders, physicians, and other health professionals.
8. Articulates the program to physicians and other health care professionals to educate and teach ambulatory clinical documentation requirements.
9. Demonstrates knowledge of coding guidelines, documentation opportunities and clinical documentation requirements.
• Associate’s Degree in Health Information Management or related field
• Certified Clinical Documentation Specialist (CCDS) or CCDS-O (outpatient), Certified Documentation Expert Outpatient (CDEO), Certified Professional Medical Auditor (CPMA) or Registered Health Information Technician (RHIT)
• Maintenance of continuing education requirements
• If qualified as an RHIT, must have at least 2 years of experience in a clinical documentation improvement role or ambulatory (professional fee) clinical documentation auditing
• If qualified as a CCDS, CCDS-O, CDEO or CPMA, must have at least 3 years of experience in a clinical documentation improvement role or ambulatory (professional fee) clinical documentation auditing