Clinical Document Improvement Specialist

Overview

About us:

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief Summary of Purpose: 

Responsible for the overall improvement of the quality, completeness and accuracy of medical record documentation through interaction with physicians and other business partners. Ensures clinical documentation reflects the level of service, severity of illness, risk of mortality is complete, accurate and successfully facilitates the accurate representation of a patient’s medical records that translates into coded data.

Responsibilities

Responsibilities: 

• Able to collaborate extensively with physicians, nurses, other caregivers, and medical records coding staff to improve quality and completeness of documentation of care provided and coded• Assist in the collection and analysis of risk adjustment data in-order to identify documentation, coding trends and opportunities• Audit medical records for accuracy of coding, ambiguous, conflicting or incomplete documentation.• Conducts concurrent review of the medical records to increase the accuracy, clarity and specificity of provider documentation.• Provide feedback to providers and external/internal business partners of audit findings and make recommendations as necessary.• Keeps current with changes in coding guidelines, compliance, reimbursement, and other relevant regulatory updates• Develop and coordinate education and training that focuses on Risk Adjustment coding and documentation opportunities utilizing a variety of methods to deliver content, such as direct provider collaboration, power point presentations, teleconferences and webinars.• Partner with key business areas around provider education, engagement and develop follow up plans where appropriate.• Collaborate with internal business partners to achieve department objectives and ensure internal risk adjustment compliance and standards are maintained• Assumes responsibility for professional development by participating in workshops, conferences and/ or in-services.• May be called on to present to large and/or small groups of executives, physicians and other clinical or financial personnel• Assist with coding chart review projects and RADV audits • May be required to Audit vendors and internal coders work

Qualifications

Education: 

• Bachelor’s degree or equivalent work experience

License/Certifications:

• Possession of AHIMA (American Health Information Management Association) or AAPC (American Academy of Professional Coders) of any of the following Certified Coding Specialist (CCS), Certified Risk Adjustment Coding (CRC) or Certified Professional Coder (CPC) required.• RN Licensure preferred

Experience:

• Strong organizational skills in multiple settings, as well as the ability to exercise judgement and initiative• Strong written, verbal and presentation skills • Possess Critical Thinking skills• Competent in MS Office• Proven/demonstrated knowledge in the following1.ICD-10-CM Coding/Risk Adjustment HCC coding2. Regulatory Compliance3. HIPAA and Legal Aspects of Health Information4. Medical Reimbursement Methodologies5. Medical Terminology• Self-motivation with excellent follow through skills with ability to work independently with minimal to moderate supervision with demonstrated ability to work as an effective team member• Adaptive and flexible to new ideas and change• Travel to provider offices • Experience working and interacting with the Provider community• Preferred: 2 year of Clinical Documentation Improvement (CDI) experience in the inpatient/outpatient setting • Thorough knowledge of ICD-10-CM, Medicare, Medicaid, Commercial HCC coding guidelines• Previous experience with Risk Adjustment coding is preferred

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.