Clinical Documentation Improvement Partner

The Clinical Documentation Improvement Partner is responsible for partnering with physician offices within our established partnerships to assist in translating healthcare documentation into standardized codes, ensuring accurate coding and billing of patient encounters, as supported by the medical record. You serve as a subject matter expert in Coding and Documentation. Primary Functions: Accurately code diagnoses based on documented information, ensuring compliance with regulatory requirements and that the assigned codes accurately represent the clinical information documented by the provider. Ensure documentation supports appropriate level(s) of care and severity of illness when applying ICD-10, CPT, and other relevant codes for billing and regulatory compliance. Maintain a 95% productivity rate. Communicate with physicians and other healthcare providers to clarify documentation, ensuring that diagnoses and procedures are properly documented in compliance with clinical standards. Issue queries to healthcare providers when documentation appears ambiguous, incomplete, or inconsistent, requesting clarification or additional details be added to the medical record to ensure accurate documentation. Ensure that the queries are compliant with industry standards and regulatory guidelines. Stay updated on current coding guidelines, clinical protocols, and regulatory changes, including Medicare and Medicaid guidelines on billing and coding, to support provider compliance therewith. Assist in improving the quality of clinical documentation to support various quality initiatives, such as HEDIS, CMS, and other contractual or enterprise-initiated performance metrics. Participate in performance improvement projects aimed at improving documentation practices and outcomes. Conduct audits of medical records to identify trends in documentation, both positive and negative, to help the organization improve documentation practices and provider education efforts. Provide ongoing education to clinical staff, coders, and other healthcare providers on best practices in clinical documentation, coding guidelines, and regulatory compliance. Develop training programs to address documentation deficiencies and improve overall documentation quality. Collaborate with departments such as compliance, revenue cycle, and quality management to optimize the documentation improvement process.