Clinical Documentation Specialist- South Bend Clinic

Overview

Clinical Documentation Specialist - South Bend Clinic

• Full-Time - 40 hours per week.
• Monday-Friday - Hours will vary.
• Location: South Bend, Indiana
  
  

The Clinical Documentation Specialist is responsible for supporting providers through education, training, and ongoing support in condition identification, documentation, and coding. This role ensures provider compliance with CMS guidelines, facilitates onboarding and continuous education for clinicians, and develops improvement plans based on chart reviews, audits, and coding performance metrics. The Clinical Documentation Specialists will build strong collaborative relationships with providers and office staff, conduct both in-person trainings, and remain current on evolving Medicare, AMA, ICD-10, and risk adjustment guidelines. Additionally, this role contributes to the development of policies, procedures, and training playbooks, supports quality improvement initiatives, and participates in team meetings, bootcamps, and other forums. Success in this position requires strong clinical knowledge, excellent communication and organizational skills, the ability to work independently in a fast-paced environment, and flexibility to travel as needed.

Responsibilities

Provides education and training to providers on accurate condition identification, documentation, and coding practices.

• Ensures compliance with CMS, HCC, and ICD-10 documentation guidelines.
• Conducts onboarding and ongoing training for new and established providers
• Develops and facilitates education sessions, bootcamps, and mini-bootcamps, including evenings or weekends as required.
• Reviews documentation for accuracy, completeness, and active diagnosis validation.
• Identifies missing treatment plans and chronic conditions requiring attention.
• Provides timely feedback and education to providers based on audit findings.

Acts as a resource for Providers and vendors

• Keeps abreast of current coding trends and maintains up to date knowledge of Medicare rules and regulations regarding diagnosis coding and CDI current trends
• Effectively utilizes ICD and related materials to investigate coding issues and produce accurate results.
• Serves as an expert resource in reviewing all medical records in support of accurate documentation for all payer types to assure complete and accurate diagnosis and procedure capture and coding.
• Reviews payer files and integrates findings into training and other educational materials
• Proactively coordinates and engages regular meetings with providers (Primary Care and Specialists)
• Leads and executes physician education strategies that result in improved clinical documentation and complete capture of diagnosis coding

Contributes to the creation, revision, and implementation of playbooks, policies, and procedures.

• Assists in developing new training content and clinical education materials.
• Prepares and presents on risk adjustment, HCC, and documentation best practices.
• Ensures educational resources remain current with industry and regulatory changes.
• Provide education on HCC conditions

Supports, monitors, and reports key performance indicators (KPIs) to Management and Senior Management

• Monitors trends in documentation including prevalence of conditions, develops and implements action plans to maximize the program.
• Reviews documentation and creates documentation feedback for each provider. Also is able to present this feedback back to the provider and track improvement.
• Develops and implements strategies, provides analysis and makes recommendation for process improvement using data anysis.
• Develops monitoring tools to track progress of the program such as identification of cases with suspect opportunities, HCC recapture rate, etc.

Builds and maintains collaborative relationships with providers, office managers, and internal teams.

• Serves as a subject matter expert and trusted advisor in documentation and coding practices.
• Supports communication between providers, medical office managers, and operations.
• Participates in weekly team meetings and collaborates on program development.
• Other duties as assigned.
  
  

Qualifications

EDUCATION:

• Bachelor's degree highly preferred.
  
  

LICENSURE/CERTIFICATION:

• Active RN license in good standing or Foreign Medical Graduate with MD (full or limited)
• CPC or CRC certification (or ability to obtain within 6 months)
  
  

EXPERIENCE:

• Minimum 2 years of experience in risk adjustment and/or clinical documentation (preferred).
  
  

The compensation for this role includes a base pay range of $85,616-$128,425, with the actual pay determined by factors such as skills, experience, education, certifications, geographic location, and internal equity. Additional compensation may be available through shift differentials, bonuses, and other incentives. Base pay is only a portion of the total rewards package.