Clinical Documentation Improvement Specialist I

Primary Duties and Responsibilities: To advise and educate Emergency Medicine, Hospital Medicine, Critical Care Medicine, Telemedicine, and Urgent Care internal and external clients (clinicians/facility/operations) on current documentation/coding requirements via phone, webinar, and/or in person for a portfolio of 5-10 contracts. To counsel clinicians identified as outliers via face-to-face interaction, phone, web-based, and/or email, on a minimum of a monthly basis or as coordinated by Director of Documentation Assurance. To perform chart analysis/recommendations to support quality documentation feedback to clinicians as it relates to CMS Guidelines, Attestations, Procedures, and internal Queries. Educate and counsel clinicians on how to resolve external chart queries. Travel to territories as required to provide in-person documentation education, oversight, feedback, and training with EMR training as needed. Participate in clinician Electronic Medical Record (EMR) training and provide feedback/clarification on documentation/coding and workflow concepts. Analyze coding and billing data to identify documentation and RVU outliers at the facility and clinician level to deliver additional documentation/coding education. Assist clinicians and chart acquisition team with chart flow process issues. Onboard and train all new clinicians on mySCP Care/mySCP Complete and the provider portal and act as a first line of contact for mySCP Care/mySCP Complete related issues and questions from clinicians and operations. Educate and give feedback to all new clinicians on documentation performance within the first month of service. Provides support to CDIS II other and/or senior CDIS as needed on major client and department initiatives. Understands the department’s strategic plans and performance measures required to support that plan. Continues to seek out tasks and other initiatives that provides the opportunity for growth and development in the CDIS field. Participate in standing clinician meetings to highlight documentation, coding, and quality initiatives. To participate in company-wide initiatives related to clinical documentation as identified by Clinical Leadership Collaborate with Data and Performance Analytics Team on clinician feedback. Conduct audits regarding clinician RVU and productivity as requested. Present Clinician Onboarding WebEx presentations bi-weekly and provide additional sessions as needed (HM) Create and distribute Monthly Facility Report Cards and trending reports to Medical Directors and Operations (HM) Knowledge, Skills, and Abilities: Maintain knowledge of EMR’s, i.e., Allscripts, Cerner, CPSI, EPIC, McKesson, Paragon, Medhost, Meditech Basic knowledge in Microsoft office suite Experience in clinician CMS documentation guidelines Ability to learn additional reporting avenues and systems EDUCATION (Required and/or Preferred): Bachelor’s degree - required Health Information Management Nursing Another related field FIELD OF STUDY (Preferred): Health Information Management (HIM), Nursing, Other healthcare related field

SUPERVISION EXERCISED: None

Previous Experience: 2 years’ experience in Hospital or Physician practice environment performing related job duties as described above. Experience with Emergency Medicine, Hospital Medicine, Urgent Care documentation and coding guidelines preferred. Experience with one or more following EMR’s: Cerner, EPIC, Medhost, or Meditech Strong skills in Microsoft Suite such as Outlook, Excel, and PowerPoint. Microsoft Excel functions include, but not limited to: Data Entry, Data Filters, Data Sorting, Pivot Tables, Charts, Formatting, and Lookup Functions Microsoft PowerPoint functions to include, but not limited to: Design, Layout, Animation, Formatting, Customization, Timing, Recording. Certification and Licenses: Registered Health Information Administration (RHIA), Documentation Improvement Practitioner (CDIP), Certified Clinical Documentation Specialist (CCDS), Certified Professional Coder (CPC), or Certified Coding Specialist (CCS) and prior intermediate coding experience CONTACTS INSIDE AND OUTSIDE THE ORGANIZATION: Internal Department - feedback and education, auditing External Department - feedback, education, auditing, communicating errors External Customer Facing - clinician education and feedback regarding chart completion Identify trends and problem resolution in clinician documentation/coding impacting billing, RVU, and Coding assignment Communication on clinician documentation issues identified with HIM, IT, Clinicians including Med Director, and SCP Operators. Communication on chart flow issues, errors, and resolution identified internally and externally

WORK ENVIRONMENT AND PHYSICAL DEMANDS: Works independently at a Clients Site / Hospital facility

PRIMARY LOCATION: Home Based or office location Lafayette, LA, Dallas, TX, or Atlanta, GA (if within 30 miles of office location) Travel to territories as required to provide in-person documentation education, EMR training as needed with EMR team, or CDIS II.

CONFIDENTIALITY: The daily activities of this position will be held in the strictest confidence whether it is in regard to a person, individual and/or a strategic initiative. Confidentiality must be maintained on any and all documents and/or information processed.

COMPLIANCE: All SCP Health employees will abide by all policies and procedures including the SCP Health Corporate Compliance Program and will adhere to all applicable local, state, and federal laws.

DISCLAIMER: The above statements reflect the general duties considered necessary to describe the essential functions of the job as identified and shall not be considered as a detailed description of all work requirements which may be inherent in the position. They may be subject to change at any time due to reasonable accommodations or other reasons.

Pay Range: 46,163.00 - 65,601.00 USD annually