Overview
The Ambulatory Fee Clinical Documentation Specialist is responsible for following ambulatory facility and clinic
processes while providing clinically based reviews of documentation to capture accurate charges for services rendered.
The Ambulatory Clinical Documentation Specialist will engage with providers to provide documentation education in
addition to providing Profee Education and training, ProFee opportunity identification and provide any additional support
to the providers as required and needed.
Responsibilities
The goal of concurrent review includes facilitation of appropriate physician documentation of care delivered to accurately reflect patient severity of illness, risk of morality and care provided.
Specific reviews are both determined internally and by requirements/requests of external payers or regulatory agencies and play a significant role in reporting quality of care outcomes and in obtaining accurate and compliant reimbursement for acute care and ambulatory services.
Duties Include
Duties include of the Ambulatory Clinical Documentation Specialist:
Conduct chart reviews of the ambulatory setting daily and as requested to regularly review the
documentation and charge accuracy and to integrate into educational sessions with the Clinical
departments and medical staff
Performs review of accounts identified or requested for potential opportunity and opportunity for
provider education. Conducts additional research to help resolve the areas of opportunity and
identify the root cause of the potential missed opportunities
Provides reporting and feedback to the Clinical Departments based on claim accuracy and chart
reviews to encourage greater understanding and ownership of documentation and charge
accuracy
Maintains current knowledge of applicable regulatory standards, which may impact utilization of
processes and systems
Demonstrates creativity and enthusiasm while pursuing the goals of the department and the
organization
Provides education to providers and other staff as deemed appropriate
Maintains the ability to be flexible and prioritizes daily responsibilities
Attends meetings, educations sessions and trainings as scheduled
Maintains strict confidentiality of all patients, employee and physician information according to
HIPAA guidelines
All other duties as assigned for both Clinical and Ambulatory Clinical Documentation Specialist
Other Job Responsibilities Include
- Shares in organization’s vision, demonstrates its values, supports its philosophy and is sensitive
to its mission. Demonstrates knowledge of and follows departmental and hospital policies and
physician office procedures
- Seeks out opportunities for individual growth and development, including attending various
meetings, conferences, courses, seeking certifications, as required.
- Uses tact and sensitivity when communicating with patients, visitors, co-workers, and other
personnel
- Serves on department and/or institutional committees as requested
Qualifications
Education
Bachelor’s, or Associate’s Degree in Nursing or Health Information Management or related field
Minimum Work Experience Minimum of 5 years of clinical experience in an acute care setting or of 5 years experience in coding in an acute hospital setting
Required Licenses/Certifications
RN, BSN, RHIA or RHIT credential required Education: Minimum Associate Degree Licensure / Certification: CCS-P, CPC, CRC, or other coding credential a. RN or LPN helpful but not required
Required Skills, Knowledge, And Abilities
- Knowledge of care delivery documentation systems and related medical record documents.
- Knowledge of age-specific needs and the elements of disease processes and related procedures.
- Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
- Excellent written and verbal communication skills.
- Excellent critical thinking skills.
- Demonstrated good nurse-physician relationships in the past and can maintain those going forward.
- Working knowledge of inpatient admission criteria.
- Ability to work independently in a time-oriented environment.
- Computer literacy and familiarity with the operation of basic office equipment.
- Assertive personality traits to facilitate ongoing physician communication.
- Ability to stand, sit and walk for periods of time is required in the performance of job responsibilities.
- Working knowledge of Medicare reimbursement system and coding structures preferred, but not required.
