Position Overview
We are seeking a highly skilled Clinical Documentation Specialist (CDS) Coordinator to support our Hospitalist Program by ensuring accurate medical documentation, optimizing coding and billing processes, and leveraging AI platforms to enhance efficiency. The CDS Coordinator will play a critical role in improving clinical documentation integrity, supporting compliance, and ensuring optimal revenue cycle management.
The ideal candidate will have expertise in coding and billing for medical practices, proficiency in Microsoft Office (with advanced Excel skills), and familiarity with AI-driven documentation tools . This role requires strong analytical abilities, attention to detail, and the ability to collaborate with providers and administrative teams to enhance documentation quality.
Key Responsibilities
Clinical Documentation & Coding Support
- Review and analyze clinical documentation to ensure accuracy, completeness, and compliance with CMS and hospital regulations.
- Work closely with hospitalists and medical staff to optimize clinical documentation practices for improved coding accuracy and reimbursement.
- Identify coding discrepancies, documentation gaps, and opportunities for coding optimization .
- Collaborate with billing teams to ensure proper coding and claim submission for hospitalist services.
Billing & Revenue Cycle Management
Ensure medical documentation supports accurate CPT, ICD-10, and DRG coding for appropriate reimbursement .Monitor billing processes and claim submissions , assisting in resolving denials and coding-related issues.Conduct periodic audits and quality checks to maintain coding and billing accuracy.Support revenue integrity by identifying and implementing best practices for clinical documentation improvement (CDI) .Technology & AI Integration
Utilize AI-driven platforms to enhance clinical documentation and coding workflows .Identify new AI tools and automation opportunities to improve efficiency in CDS operations.Train hospitalist staff on AI-powered documentation support tools .Data Analysis & Reporting
Use advanced Excel functions (pivot tables, VLOOKUP, data visualization tools) to analyze clinical and financial data.Generate reports on documentation trends, billing accuracy, and revenue impact for leadership review.Provide feedback and education to hospitalists and coders based on data-driven insights.Compliance & Quality Assurance
Ensure adherence to HIPAA, CMS, and payer-specific documentation requirements .Stay up to date with coding, billing, and compliance regulations , and educate hospitalist staff accordingly.Assist with internal and external audits , providing necessary documentation and explanations.Qualifications & Requirements
Associate's or Bachelor's degree in Health Information Management , Medical Coding, or a related field preferred.Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Clinical Documentation Improvement (CDI) certification is highly desirable.Minimum of 3-5 years of experience in medical coding, billing, and clinical documentation improvement.Strong understanding of hospitalist billing, inpatient and outpatient coding, and CMS regulations .Proficiency in Microsoft Office Suite, with advanced Excel skills (pivot tables, VLOOKUP, data analysis tools) .Familiarity with AI-driven documentation tools and electronic medical record (EMR) systems .Excellent communication and collaboration skills , with the ability to work closely with providers and administrative staff.Strong problem-solving and analytical abilities to identify documentation and billing inefficiencies.
