Coding and Clinical Documentation Specialist

#WFH
#Direct Client
#Full Time - 8am-5pm PST/ CST/ EST

We are a dedicated telehealth clinic specializing in obesity management and committed to delivering personalized, high-quality care to our patients. Our mission is to empower patients on their journey to better health. Join our team and help us improve health outcomes by supporting accurate and compliant documentation and coding practices.

Position Overview

The Coding and Clinical Documentation Specialist is responsible for ensuring that clinical documentation accurately reflects the services provided and aligns with regulatory requirements. This role plays a key part in optimizing coding accuracy, improving reimbursement processes, and supporting the clinic's commitment to compliance and high-quality patient care. The ideal candidate will have a strong background in medical coding, clinical documentation improvement (CDI), and familiarity with telehealth standards.

Key Responsibilities

Medical Coding
? Review and assign accurate ICD-10, CPT, and HCPCS codes to patient diagnoses and procedures, following industry and regulatory standards.
? Work closely with clinical staff to ensure accurate and complete coding that reflects the services provided, maintaining compliance with federal and state regulations.
? Monitor and apply updates to coding guidelines, ensuring that all codes reflect the most current practices.

Clinical Documentation Improvement (CDI)
? Evaluate clinical documentation to ensure it supports the assigned codes and provides an accurate portrayal of patient health status and care provided.
? Collaborate with healthcare providers to clarify documentation and provide guidance on proper coding practices to optimize coding accuracy.
? Conduct regular documentation audits and develop improvement plans to address any identified gaps or discrepancies.

Compliance and Quality Assurance
? Ensure compliance with healthcare regulations, including HIPAA, CMS guidelines, and coding standards to minimize risk and protect patient information.
? Participate in internal and external audits, providing documentation and insight to maintain compliance with coding standards.
? Implement quality assurance measures to continually improve coding and documentation accuracy, reducing denials and optimizing reimbursement.

Training and Education
? Conduct training sessions for clinical staff on accurate documentation practices, coding updates, and telehealth documentation requirements.
? Act as a resource for clinic staff on coding questions, clarifications, and best practices.

Reporting and Analysis
? Generate reports on coding accuracy, error rates, and reimbursement trends to provide actionable insights for management.
? Analyze coding and documentation trends to support continuous improvement in clinical documentation and coding practices.

Qualifications

? Education: Associate’s or Bachelor’s degree in Health Information Management, Health Informatics, or a related field.
? Certification: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Clinical Documentation Specialist (CCDS) is preferred but not required.

? Experience:
? Minimum of 3 years of experience in medical coding and clinical documentation, preferably in telehealth, obesity management, or a related healthcare specialty.
? Familiarity with Electronic Health Records (EHR) systems, such as DrChrono, Epic, Cerner, or AthenaHealth, is strongly preferred.

? Skills:
? Proficiency in ICD-10, CPT, and HCPCS coding with in-depth knowledge of coding guidelines and compliance requirements.
? Strong analytical and problem-solving skills, with excellent attention to detail.
? Effective communication skills, with the ability to collaborate with clinicians and support staff.

? Attributes:
? Highly organized, self-motivated, and able to manage multiple tasks and deadlines.
? Strong ethical standards and commitment to confidentiality and accuracy.
? Ability to adapt to evolving healthcare regulations and coding standards.

If this sounds like you, we encourage you to submit your resume and a cover letter detailing your interest in the role to [email protected]. Please use the subject line: Coding and Clinical Documentation Specialist_Application. Be sure to review the full job description before applying.