About This Role
The Clinical Documentation Specialist ensures that all clinical and operational documentation and coding practices comply with federal, state, and Tribal regulations. This role involves performing audits, evaluating compliance, and providing education across various clinical and operational teams, particularly supporting Indian Health Service (IHS) contracts and Tribal health system requirements.
Responsibilities
- Establish and maintain a formal documentation and coding audit program
- Conduct routine and targeted audits to validate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD 10 CM), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and Procedure Coding System (PCS) code accuracy
- Perform prospective and retrospective reviews to ensure medical necessity and documentation sufficiency
- Analyze audit findings; prepare reports; deliver provider specific education
- Develop follow up audits and documentation improvement plans
- Provide coding guidance across inpatient, outpatient, professional, surgical, home health, and ancillary services
- Design and deliver training programs for compliant coding and billing aligned with regulatory requirements
- Evaluate vendor training materials for applicability across KDC operations and Tribal/IHS contract environments
- Maintain current knowledge of federal/state regulatory changes; update training materials accordingly
- Participate in committees, operational initiatives, and compliance reviews
- Support documentation improvement efforts tied to grants, proposals, and contract deliverables
- Ensure documentation practices align with Centers for Medicare & Medicaid Services (CMS), Health Resources and Services Administration (HRSA), and Indian Health Service (IHS) requirements
- Collaborate with Revenue Cycle and Quality teams to reduce denials related to documentation insufficiency and medical necessity
- Assist in preparing documentation components for Prospective Payment System (PPS), All Inclusive Rate (AIR), and wrap around reimbursement submissions
- Perform additional duties as assigned
- Travel to customer site periodically as needed (up to 40%)
Requirements
- Minimum 5 years acute care coding experience
- Required certification: Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Certified Coding Specialist – Physician based (CCS P), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Registered Health Information Administrator (RHIA)
- Knowledge of documentation requirements for value based care, Alternative Payment Models (APMs), and federal contract deliverables
- Proficiency with Electronic Health Record (EHR) systems used in Tribal/IHS settings (e.g., RPMS, Cerner, Epic)
