Outpatient Clinical Documentation Specialist

Job Summary

To enhance risk adjustment outcomes, the full-time Remote Outpatient Clinical Documentation Specialist will review patient records, validate diagnoses, and query providers to ensure accurate clinical documentation supporting HCC and condition-related diagnoses.

Key responsibilities

• Perform reviews of patient records to identify and validate Hierarchical Condition Category (HCC) diagnoses
• Create queries reflective of best practices to ensure accurate and complete documentation
• Formulate recommendations to improve clinical logic and workflows based on documentation quality assessments

Required qualifications

• Graduate of an accredited nursing education program
• Active and unrestricted Registered Nurse or Advanced Practice Provider license
• Certification as a Documentation Expert-Outpatient (CDEO), Clinical Documentation Specialist-Outpatient (CCDS-O), or Certified Documentation Improvement Practitioner (CDIP) and Certified Risk Adjustment Coder (CRC)
• Minimum of 2 years of outpatient Clinical Documentation Improvement (CDI) experience
• Experience navigating Epic, Athena, and Cerner electronic medical records (EMRs)