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.
**Buffalo, NY**