Clinical Documentation Specialist

What you can expect! 

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Reporting to the Director, Payor Relations, the Clinical Documentation Specialist performs a wide variety of audit services including charge audit, compliance audit, medical necessity, as well as appeals and denials to ensure that documentation meets clinical guidelines and supports billed items and services. This position facilitates reviews of member accounts/claims to ensure that the health record is coded accurately and reflects the clinical scenario within the health record, noting compliance with coding guidelines and identifying opportunities for improvement in documentation and in the quality of care. The Clinical Documentation Specialist audits itemized charges versus the member’s medical record and other applicable documentation, reviews the appropriateness of assigned modifiers to claims, research edit claims for medical necessity and advises billing staff of appropriate codes and modifiers. The role works directly with various internal and external departments and stakeholders regarding proper coding and charging and provides relevant education based on identified needs.

Key Responsibilities:

1. Coordinate, supervise, and perform audits in a timely manner, ensuring compliance with billing guidelines:
- Receive, review, verify, and process chart audits of inpatient hospitalizations, diagnostic testing, outpatient procedures and services, home health care services, durable medical equipment, rehabilitative therapies, and pharmacy reviews.
- Review patient records for accurate coding, sequencing of diagnoses and procedures following the ICD-10-CM, ICD-10-PCS, Uniform Hospital Data Set, Medicare, Medicaid, commercial payor, and other fiscal intermediary guidelines.
- Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification.
- Identify potential claims where additional recoveries may be available.
- Incorporate policies and procedures, internal controls, guidelines and standards of practice in determining compliance.
2. Effectively utilize audit tools with high level of proficiency and achieve expected levels of accuracy and quality for auditing, valid claim identification and documentation/letter writing. Write detailed, accurate, and concise rationale and provides supporting evidence for recommendations and findings using appropriate guidelines. Maintain audit documentation, records review decisions and justifications for changes requested or issues raised.
3. Recommend and develop high-quality, high-value auditing concepts, workflows and process improvement tools, materials, and activities. Evaluate algorithms, review data sets, independently solve problems, research data anomalies, and track audit trends. Create audit letter templates for utilization within the review, audit, and appeals process. Provide effective written explanations of audit findings for a variety of clinical and non-clinical stakeholders.
4. Interact with providers and other stakeholders to reconcile issues affecting coding, including denials, coding errors, DRG mismatches, guideline clarifications, clinical documentation, billing practices, and technical issues. 
5. Create training materials and provide educational activities for various stakeholders regarding appropriate charging process and procedures that will guide the implementation of actions to prevent future improper payments, and other topics related to subject matter expertise, and developments in the field.
6. Maintain reporting system of audit activities and identify patterns and trends. Prepare written reports on the outcomes of audit results, including explanations for recovery, and assist with mitigation efforts.
Provide feedback and process improvement recommendations to appropriate plan and hospital departments and committees based on analysis and trending of audit results.
Provide support and expertise to other investigative and analytical areas.
7. Perform any other duties as required to ensure Health Plan operations and department business needs are successful.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members; we also aim to match our Team Members with the same energy by providing prime benefits and more.

• CalPERS retirement
• 457(b) option with a contribution match
• Generous paid time off- vacation, holidays, sick
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Paid life insurance for employees with additional options
• Short-term, and long-term disability options
• Pet care insurance
• Flexible Spending Account – Health Care/Childcare
• Wellness programs that promote a healthy work-life balance
• Career advancement opportunities and professional development
• Competitive salary with annual merit increase
• Team bonus opportunities

Education & Experience

• Five (5) years inpatient coding experience. Three (3) years clinical experience in a hospital setting. Three (3) years of experience in clinical documentation. Auditing experience in provider or payor environment. Experience with medical necessity determinations applying clinical judgment, utilizing medical necessity criteria and screening based on nationally recognized tools. Experience with multiple EMR systems such as Epic, Cerner, Meditech.
• Bachelor’s degree in Nursing or foreign medical graduate from an accredited institution required.

• One (1) of the following certifications is required:

  • RHIA

  • RHIT

  • CCS

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP) required upon hire or commitment to obtain within six (6) months of hire.

• Candidates who are not foreign medical graduates: Possession of an active, unrestricted and unencumbered Registered Nurse (RN) license issued by the California Board of Nursing required.

Key Qualifications

• Excellent customer relations. Excellent verbal and written communication.
• Able to work independently with attention to detail and accuracy.
• Ability to utilize a computerized encoding system to facilitate accurate coding.
• Ability to sequence diagnoses and procedures by following the ICD-10-CM, Uniform Hospital Data Set, Medicare, Medicaid, and other fiscal intermediary guidelines.
• Strong quantitative, analytical and organizational skills.
• Extensive ICD-10-CM/PCS coding knowledge, including but not limited to, principal diagnosis selection, present on admission indicators (POA), complications/comorbidities (CC), major complications/comorbidities (MCCs), conditions that impact severity of illness (SOI), and risk of mortality (ROM).
• High level of understanding in reimbursement guidelines, specifically of the MS-DRG, AP-DRG and APR-DRG payment systems.
• Strong familiarity with clinical documentation improvement practices or inpatient claims
• Solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and experience with ICD-10-PCS and CPT code assignment
• Strong knowledge and adherence to the Health Insurance Portability and Accountability Act (HIPAA)
• Broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and regulatory guidelines.
• Familiarity with coding diagnostic and procedural information from the record using ICD-10-CM and CPT-4/HCPCS classification systems

Start your journey towards a thriving future with IEHP and apply TODAY!