Outpatient (RN) 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

Minimum Education and Requirements:

Bachelor's degree in nursing from an accredited school of nursing and at least five years' clinical nursing experience preferred. Strong clinical experience and critical thinking skills required.  Extensive knowledge of patient care, and knowledge of clinical measurement tools and clinical outcomes; ability to establish cooperative working relationships with diverse groups and individuals, medical staff and other health care disciplines. Licensure as a registered nurse by the South Carolina Board of Nursing or compact state.  

Job Preference:

• Registered Nurse with at least 3 or more years of experience either in the clinical field, CDI field, or coding.
• 1 or more years of 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.

Preferred and Highly Encouraged Certifications/Licensure:

• Active certification from one of the following preferred:
• AAPC (Certified Professional Coder - CPC, Certified Risk Adjustment Coder – CRC 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.

Additional Job Description:

Clinical Documentation Improvement: (50%)

• 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.
• Collaborate with physicians, nurse practitioners, case managers and coders to identify opportunities for improving documentation of diagnoses, procedures and medical necessity.
• Query providers in a compliant and clear manner to address documentation gaps, ambiguities or discrepancies to support accurate coding and billing.
• Educate providers and clinical staff on best practices for documentation to improve encounter accuracy and quality.

Outpatient HCC Coding: (25%)

• Accurately assign ICD-10 CM for outpatient encounters, including clinical visits, emergency department visits, ambulatory surgeries, laboratory services and observation care.  
• Abstract data and input into electronic medical record systems while adhering to organizational and regulatory coding standards.
• Ensure coding accuracy meets or exceeds a 95% accuracy rate, following official ICD-10-CM guidelines.

Data Integrity and Compliance (15%):

• Maintain complete confidentiality of patient information and adhere to HIPAA regulations and organizational policies.
• Ensure documentation and coding practices meet compliance standards for regulatory and payer requirements.

Collaboration and Education (10%):

• Act as a liaison between clinical providers and HIM to bridge the gap between documentation and coding requirements.
• Participate in education for providers on coding and documentation standards, focusing on outpatient services.
• Participate in ongoing education and stay current with changes in coding guidelines, CDI practices, and healthcare regulations.
  

Additional Job Description

Physical Requirements

• Mobility & Posture

Standing: Continuous, Sitting: Continuous, Walking: Continuous, climbing stairs: Infrequent, working indoors: Continuous, working outdoors (temperature extremes): Infrequent, working from elevated areas: Frequent, working in confined/cramped spaces: Frequent, Kneeling: Infrequent, bending at the waist: Continuous, Twisting at the waist: Frequent, Squatting: Frequent

• Manual Dexterity & Strength

Pinching operations: Frequent, Gross motor use (fingers/hands): Continuous, Firm grasping (fingers/hands): Continuous, Fine manipulation (fingers/hands): Continuous, reaching overhead: Frequent, Reaching in all directions: Continuous, Repetitive motion (hands/wrists/elbows/shoulders): Continuous, Full use of both legs: Continuous, Balance & coordination (lower extremities): Frequent.

• Lifting & Force Requirements

Lift/carry 50 lbs. unassisted: Infrequent, Lift/lower 50 lbs. from floor to 36”: Infrequent, Lift up to 25 lbs. overhead: Infrequent, Exert up to 50 lbs. of force: Frequent

• Vision & Sensory

Maintain corrected vision 20/40 (one or both eyes): Continuous, Recognize objects (near/far): Continuous, Color discrimination: Continuous, Depth perception: Continuous, Peripheral vision: Continuous, Hearing acuity (with correction): Continuous, Tactile sensory function: Continuous, Gross motor with fine motor coordination: Continuous.

• Selected Positions:
  • Olfactory (smell) function: Continuous
  • Respirator use qualification: Continuous

• Work Environment & Conditions

Effective stress management: Continuous, Rotating shifts: Frequent, Overtime as required: Frequent, Latex-safe environment: Continuous.

If you like working with energetic enthusiastic individuals, you will enjoy your career with us!