Outpatient Clinical Documentation Specialist

Inova Health System is looking for a dedicated Outpatient Clinical Documentation Specialist to join the team. This role is Full-time working 8am-4:30pm Monday to Friday, REMOTE. ***Must have required certifications and experience***

Inova is consistently ranked a national healthcare leader in safety, quality and patient experience. We are also proud to be consistently recognized as a top employer in both the D.C. metro area and the nation.

Featured Benefits:

• Committed to Team Member Health: offering medical, dental and vision coverage, and a robust team member wellness program.
• Retirement: Inova matches the first 5% of eligible contributions - starting on your first day.
• Tuition and Student Loan Assistance: offering up to $5,250 per year in education assistance and up to $10,000 for student loans.
• Mental Health Support: offering all Inova team members, their spouses/partners, and their children 25 mental health coaching or therapy sessions, per person, per year, at no cost.
• Work/Life Balance: offering paid time off, paid parental leave, flexible work schedules.

Outpatient Clinical Documentation Specialist Job Responsibilities:

• Conducts initial and follow-up concurrent reviews of medical records for assigned patients in the timeframe and frequency defined for productive work.
• Identifies appropriate clinical documentation to support HCC, ICD-10-CM specificity, HCPCS, CPT, Modifiers, and medical necessity of ambulatory visits.
• Identifies the need to clarify incomplete or conflicting documentation in medical records and prepares a compliant written query for the responsible treating physician. Option also exists to interact with responsible treating physicians via a verbal query in accordance with compliance requirements. Continues to track the occurrence of physician response documented in the medical record.
• Documents findings on worksheets, denoting all key information utilized in the tracking process. Enters data into Clinical Documentation Integrity System (CDIS) Outpatient when applicable.
• Works with the Program Manager and responsible physician administrator or physician advisor regarding treating physician compliance issues such as non-response to queries and questionable clinical validity of documented diagnoses.
• Routinely provides one-on-one education to new and established physicians, advanced practice providers, and other key healthcare providers regarding the need for accurate, specific, and complete clinical documentation in the patient's medical record.
• Interacts regularly with physicians, in the outpatient setting, providing ongoing education regarding compliant documentation.
• May perform additional duties as assigned

Outpatient Clinical Documentation Specialist Additional Requirements:

• Work schedule: Full-time working 8am-4:30pm Monday to Friday, REMOTE.
• Education: High School Diploma
• Experience: Five (5) years healthcare physician/facility related experience in auditing.
• Certification: Completion of an approved coding or health information technology program with current certification(s), such as RHIA, RHIT, CCS, CCS-P or CPC, CPMA, CRC, with Clinical Documentation certification required within 2 years of hire.

About Inova Health System

We are Inova, Northern Virginia's leading nonprofit healthcare provider. Every day, our 24,000+ team members provide world-class healthcare to the communities we serve. Our people are the reason we're a national leader in healthcare safety, quality and patient experience. And from best-in-class facilities to professional development opportunities, we support them at every step. At Inova, we're constantly striving to be ever better - to shape a more compassionate future for healthcare.