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Clinical Documentation Specialist Outpatient

**Location:** Buffalo General Medical Center

Location of Job: US:NY:Buffalo

Work Type: Full-Time

**Shift:** Shift 1

Job Description

Summary:

The Outpatient Clinical Documentation Specialist (CDS) will perform concurrent and retrospective compliance reviews of the coding and documentation of diagnoses, medical procedures, and patient encounters by Kaleida Health clinical services providers Physician, Advanced Care Practitioners, and billing providers) who submit for professional fee reimbursement.

Review clinical documentation for opportunities to improve Provider documentation related to ICD-10 and CPT-4 coding and gaps in the clinical documentation. Facilitate modifications to clinical documentation through concurrent interaction with physicians/clinical staff, Medical Directors, CMO's, and clinic leadership to ensure that clinical information is captured to support the level of service rendered, risk adjustment of the patient population, and the appropriate data and reimbursement.

Provide education regarding E&M level assignments, Diagnoses and Procedure documentation, coding, and modifier use. Serve as a resource to the clinic personnel that are responsible for billing the claim as well as the surgical and ambulatory procedure billing Personnel. Assist with analysis, trending, and presentation of audit/review findings, potential issues, and their root cause. Support development of templates, databases and other tools to support accurate documentation. Manage special projects individually or in collaboration with other departments. Projects may include staff training, focused provider audits and education, special coding reviews or committees, EMR documentation template and charge process development, and other projects as directed. Assist in staff development and training.

Education And Credentials

Responsibilities:

High School Diploma or GED required. Associate of Applied Science preferred. ICD-10 and CPT-4 coding preferred.Certified Coding Spec (CCS) or Certified Professional Coder (CPC)or Reg Health Info Tech (RHIT) or Reg Health Info Admin (RHIA)required. Certified Clinical Documentation Specialist (CCDS) preferred. Certified Professional Coder- Certified Evaluation & Management Coder(CPC-CEMC) preferred.

Experience

Other information:

2 years of experience in Analytical thinking, problem solving, verbal and written communication. required. Team player in a professional environment required. Microsoft Office(Excel, Word) and Internet required. 2 years of experience in Health Information/Coding in a clinic or ambulatory surgery setting preferred. 1 year of experience in Federal, state, and private payer regulations and health care reform as it relates to changes in chart review preferred.

Working Conditions

Working conditions:

Essential:

* Weight Requirement - Light (up to 20 lbs)

Job Details

Department: KH Patient Financial Services

Standard Hours Bi-Weekly: 75.00

Weekend/Holiday Requirement: No

On Call Required: No

**With Rotation:** No

**Scheduled Work Hours:** 6a-2p; 6:30a-2:30p; 7a-3p; 7:30a-3:30p; 8a-4p; 8:30a-4:30p;

Work Arrangement: Onsite

Union Code: N00 - Non Union KH

Requisition ID#: 572

Recruiter: Ron Nobela

Grade: EX213

Pay Frequency: Bi-Weekly

**Salary Range:** $67,938.00 - $93,414.75

*Wage will be determined based on factors such as candidate's experience, qualifications, internal equity, and any applicable collective bargaining agreement.

_Kaleida Health’s mission is to advance the health of our community, and we believe our diversity, equity, and inclusion (DEI) strategic work is mission- critical for the good of our workforce and the community who need and depend on our care and services. We understand that racism and health inequities stand firmly in the way of advancing the health of our community, and Kaleida Health envisions DEI as the pursuit of equity and restorative justice for every person. We will exemplify courage and accountability through both the professing and practice of our core values for our friends, colleagues, and community. Kaleida Health is committed to creating a culture of equity and inclusion where diversity is valued and celebrated!_

**Position** Clinical Documentation Specialist Outpatient

**Location** US:NY:Buffalo | Corporate Administration | Full-Time

**Req ID** null

Equal Opportunity Employer

Kaleida Health is committed to diversity and believes our workforce is strengthened by the inclusion of and respect for our differences.

Kaleida Health is an equal opportunity and affirmative action employer. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, religion, sex, national origin, citizenship status, creed, gender, gender identity or expression, sexual orientation, disability, veteran status or any other factor which cannot lawfully be used as a basis for an employment decision.

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for or perform your job.