Outpatient CDI Specialist

Job Description Summary

The Outpatient CDI Specialist is a hybrid role that combines the expertise of clinical documentation improvement (CDI) and outpatient Hierarchical Condition Category (HCC) coding. This position will report to the Outpatient CDI Program Manager. This position focuses on improving the accuracy, quality, and completeness of clinical documentation in outpatient medical records while ensuring compliance with coding guidelines. The specialist will work collaboratively with providers, coding teams, and other healthcare professionals to facilitate accurate coding, improve risk capture, and optimize reimbursement while reflecting the true severity of illness and care provided.

Entity

Medical University Hospital Authority (MUHA)

Worker Type

Employee

Worker Sub-Type​

Regular

Cost Center

CC005475 SYS - Outpatient CDI Program

Pay Rate Type

Salary

Pay Grade

Health-28

Scheduled Weekly Hours

40

Work Shift

Job Description

The Outpatient CDI Specialist is a hybrid role that combines the expertise of clinical documentation improvement (CDI) and outpatient Hierarchical Condition Category (HCC) coding. This position will report to the Outpatient CDI Program Manager. This position focuses on improving the accuracy, quality, and completeness of clinical documentation in outpatient medical records while ensuring compliance with coding guidelines. The specialist will work collaboratively with providers, coding teams, and other healthcare professionals to facilitate accurate coding, improve risk capture, and optimize reimbursement while reflecting the true severity of illness and care provided.

Job Specifications:

· Registered Nurse (RN) with at least 3 or more years' experience either in the clinical field (RN), CDI field, or coding field required.

· 1 or more years' experience in HCC/Risk Adjustment preferred.

· Minimum of 3 years of experience in clinical documentation improvement, outpatient Hierarchical Condition Category (HCC), or a combination of both preferred.

· Experience in an outpatient or acute care setting required.

· Ability to work independently, be resourceful, and possess strong organizational skills.

· Ability to communicate effectively with physicians and other clinical staff; be courteous and professional.

Required certifications/Licensure:

Active certification from one of the following preferred:

· AAPC (Certified Professional Coder - CPC, or Certified Documentation Expert – Outpatient CDEO)

· AHIMA (Certified Coding Specialist – CCS or Certified Documentation Improvement Practitioner – CDIP)

· ACDIS (Certified Clinical Documentation Specialist - CCDS or CCDS-O)

· Candidates without a certification must obtain one within the first year of employment.

· Proficiency in ICD-10-CM preferred.

Job Responsibilities:

Clinical Documentation Improvement: (50%)

1. Conduct concurrent and retrospective reviews of medical records to ensure clinical documentation captures the full scope of patient severity, risk of mortality and medical necessity for outpatient services.

2. Collaborate with physicians, nurse practitioners, case managers and coder to identify opportunities for improving documentation of diagnoses, procedures and medical necessity.

3. Query providers in a compliant and clear manner to address documentation gaps, ambiguities or discrepancies to support accurate coding and billing.

4. Educate providers and clinical staff on best practices for documentation to improve encounter accuracy and quality.

Outpatient HCC coding: (25%)

1. Accurately assign ICD-10 CM for outpatient encounters, including clinical visits, emergency department visits, ambulatory surgeries, laboratory services and observation care.

2. Abstract data and input into electronic medical record systems while adhering to organizational and regulatory coding standards.

3. Ensure coding accuracy meets or exceeds a 95% accuracy rate, following official ICD-10-CM guidelines.

Data Integrity and Compliance (15%):

1. Maintain complete confidentiality of patient information and adhere to HIPAA regulations and organizational policies.

2. Ensure documentation and coding practices meet compliance standards for regulatory and payer requirements.