Clinical Coding / Documentation Improvement Specialist

The Clinical Coding / Documentation Improvement Specialist (Quality Improvement / Medicare Risk Adjustment – QI/MRA/UM/Care Coordinator) monitors and audits medical record documentation, coding and quality measures, utilization and billing in practice offices. This role requires knowledge of 5 STAR, PQRS, HEDIS, CMS coding and billing guidelines, clinical standards, practice guidelines, utilization management, and outcomes management.

Uses knowledge of ICD-9/ICD-10, CPT, and documentation guidelines, along with clinical skills and practice management knowledge to assist in coding/documentation audits and billing functions while ensuring that all quality measures are completed annually for patient populations in Managed Care and Medicare. Performs analytics on practice expenditures for clinical care and manages utilization appropriately.

Skills include effective communication, critical thinking, computer/EHR proficiency, clinical background, understanding of clinical guidelines, travel ability, medical records analysis, clinical correlations, proficiency with ICD-10 and CPT codes and QIP measures (CPC or CSSP), and understanding coding and billing guidelines and care management principles.

Duties include performing audits of documentation, coding, and billing practices; following current documentation and coding guidelines; querying providers for coding specificity; maintaining chronic condition lists; working on missing condition reports; assisting with quality measure initiatives; analyzing and planning utilization practices; assisting in care coordination; educating office staff and providers; reporting issues; and performing other coding and documentation reviews as needed.

Candidates should have some clinical background and current ICD-10 coding certification or equivalent. 1-2 years coding experience in any medical field or demonstrate proficiency via test. Experience with MRA reimbursement required. Must obtain CPC certification within 1 year of hire.

Must have ability to read and write correspondence, present information effectively, and knowledge of Microsoft Word, Excel, Internet, Email, and insurance websites.

Work environment is moderate noise. Physical demands include sitting, using hands and arms, talking, hearing, and close vision ability.

Benefits include 401(k), dental, health, life, vision insurance, and paid time off.

Work is in person in Miami, FL.