Clinical Documentation Specialist II

At SCP Health what you do matters

As part of the SCP Health team you have an opportunity to make a difference. At our core we work to bring hospitals and healers together in the pursuit of clinical effectiveness. With a portfolio of over 8 million patients 7500 providers 30 states and 400 healthcare facilities SCP Health is a leader in clinical practice management spanning the entire continuum of care including emergency medicine hospital medicine wellness telemedicine intensive care and ambulatory care.

Why you will love working here:

- Strong track record of providing excellent work/life balance.

- Comprehensive benefits package and competitive compensation.

- Commitment to fostering an inclusive culture of belonging and empowerment through our core values - collaboration courage agility and respect.

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 minimum portfolio of 30 diverse 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.
• Understands and provides support to or lead specific task focused on the seamless implementation of the EMR documentation strategic plan. Continues to seek out tasks and other initiatives that provides the opportunity for growth and development in the CDIS field. Provides support to junior team members using educational tools videos and provided Webexs.
• 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 EMRs 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):

• Bachelors 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

QUALIFICATIONS:

Previous Experience:

• 4 years of job specific experience in Hospital or Physician practice environment
• Experience with Emergency Medicine Hospital Medicine Urgent Care documentation and coding guidelines preferred
• Experience with one or more following EMRs: 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:

Examples of the information needed:

• Internal Department - feedback and education auditing EMR training and reporting metrics.
• External Department - feedback education EMR feedback training auditing communicating errors and responding to reviews/issues Provider Finance and Analytics
• External Customer Facing - clinicians education and feedback EMR training reporting metrics.
• Facility leaders / HIM - report metrics auditing education and feedback EMR training communication

• Identify trends and problem resolution in clinician documentation/coding impacting billing RVU and Coding assignment.
• Communication on clinician documentation issues identified with Facility C-Suite 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
• Intermittent travel averaging 40% - 75%
• Professional setting
• Continuous sitting
• Continuous oral & written communication and listening skills
• Continuous computer use
• Occasional bending kneeling lifting pulling & pushing up to 10 pounds
• Job requires a high level of mental awareness

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