The HCC-Clinical Documentation Specialist will provide active, prospective and retrospective review of provider hierarchical categorical condition coding and documentation, query for clarification, provide feedback, and educate clinical care providers to improve the documentation of all chronic conditions, treatments and care plans within the health record to accurately reflect the clinical acuity, condition of the patient and to promote patient care.
In addition, the HCC-CDS will work with the physicians to ensure high quality documentation that supports accurate representation of the annual re-assessment of the care plan for addressing chronic conditions. The HCC-CDS also works with outpatient care teams and IT support resources to anticipate and optimize annual wellness visits and associated workflows, modifying documentation support tools as appropriate.
The HCC-CDS exhibits a comprehensive knowledge of HCC clinical documentation requirements, Risk Adjustment Factor assignment, clinical conditions or procedures, and understanding of coding concepts and guidelines. The CDS is also responsible for communicating and educating members of the patients outpatient care team regarding documentation guidelines; and collaborating with other stakeholders throughout OHSU, including Quality; Enterprise Coding; Contracting, and Integrity.
Associates degree in Healthcare, Business or related field plus 3 years of experience in a Clinical Documentation Improvement program;
OR Equivalent combination of education and experience.
Must be able to perform the essential functions of the position with or without accommodation
External applicants- training in HCCs and Clinical Documentation Improvement through ACDIS or AHIMA
2-3 years of experience in a Clinical Documentation Integrity program with experience in clinical quality, utilization management, case management, or related field
Minimum of 4 years professional or hospital (depending on position) experience reviewing, abstracting, coding in ICD 10 CM or ICD 10 PCS, or CPT
Knowledge of hierarchical condition coding and RAF scoring.
Excellent observation skills, analytical and critical thinking, problem solving with good verbal and written communication skills.
Knowledge of age specific needs and the elements of disease processes and related procedures for the targeted patient population.
Clinical knowledge and understanding of pathology/physiology of disease processes.
Strong understanding of reimbursement and coding methodologies and guidelines; MS-DRGs; Severity of Illness, Risk of Mortality, Medical Necessity, Core and Quality Measures and impact of Length of Stay.
Strong understanding of medical terminology.
Ability to work independently in time sensitive environment.
Ability to work as a part of a multidisciplinary team.
Ability to assess, evaluate and teach key concepts related to documentation improvement.
Time management and project
Management skills. Proficiency in computer use and windows based applications.
Certification in one of the following (as indicated by the position description):
Coding certification from AAPC or AHIMA:
Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) through the American Health Information Management Association (AHIMA).
Active AHIMA membership may be required for some positions. Certified Professional Coder (CPC) through the American Academy of Professional Coders;
OR equivalent certification
Oregon Health & Science University values a diverse and culturally competent workforce. We are proud of our commitment to being an equal opportunity, affirmative action organization that does not discriminate against applicants on the basis of any protected class status, including disability status and protected veteran status. Individuals with diverse backgrounds and those who promote diversity and a culture of inclusion are encouraged to apply. To request reasonable accommodation contact the Affirmative Action and Equal Opportunity Department at 503-494-5148 or email@example.com.
As the state's only health and research university, OHSU brings together patient care, research, education of the next generation of health care providers and scientists and community service to improve the health and well-being of all Oregonians.The university is a conduit for learning for more than 2,800 students, providing training to interns, residents and fellows in postgraduate medical and research. It is the only place in Oregon that grants doctoral degrees in medicine, dentistry and nursing. OHSU cares for more than 251,000 patients each year from around the region and takes a leadership role in contributing to solutions involving the health of the state and the nation, such as health care access and transparency, ethics and workforce shortage. Beyond providing critical health care services, quality education and cutting-edge research, OHSU also is a key economic and social force in the Northwest. With an annual operating budget of $2.06 billion and more than 14,000 employees, OHSU is Portland?s largest employer. Its size contributes to its ability to provide... many services and community support activities not found anywhere else in Oregon. For more information visit http://www.ohsu.edu/xd/about/index.cfm