As a Quality Documentation Advisor, you will partner with physician offices, vendors and APP's within our established partnerships to assess the health information that includes improving clinical documentation, quality measures, and regulatory guidelines. The Quality Documentation Advisor will work in collaboration with the Medical Coder, as appropriate. You serve as a subject matter expert in clinical documentation, quality measures, and regulatory guidelines.
Primary functions of the Quality Documentation Specialist include:
Work collaboratively with physicians, Advanced Practice Practitioners, other healthcare professionals, and coding staff to ensure that clinical information in the medical record is current and accurate so that the appropriate utilization, clinical severity, outcomes, and quality are captured for the level of service rendered to all patients.
Perform Quality Documentation Reviews (QDR) to validate that documentation supports diagnoses, procedures, and treatment as well as identifies deficiencies of evidence-based practices.
Quality Documentation Advisor provides feedback to providers to improve clinical documentation and facilitate ongoing documentation improvement to meet all requirements of the medical record within Value-Based Care.
Serves as a resource for documentation improvement, including the ability to develop and maintain educational materials, including delivery either in-person or virtually to advanced practice clinicians and physicians.
Apply critical thinking and decision-making skills to determine if the medical record documentation supports the need for service while maintaining production goals and quality standards, including performing quality assurance reviews.
Assists management with training new Quality Documentation Reviewers to include daily monitoring, mentoring, feedback, and education.
Attend training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
Actively demonstrates the organization’s mission and core values and conducts oneself at all times in a manner consistent with these values.
Knows and adheres to all laws and regulations pertaining to patient health, safety, and medical information.
How You Qualify
You reviewed the Who You Are section of this job posting and immediately felt the need to read on. That makes you a match for our innovative culture.
You have completed an accredited program for Nurse Practitioner (NP) or Physician Assistant (PA-C).
You hold an unrestricted NP or PA state license, including board certification
You have strong comprehension of clinical standards of care and are focused on quality of life for your patients.
CMS HCC Risk Adjustment experience.
1+ years of Clinical Documentation Integrity experience.
3+ years of clinical practice in a hospital, home care, or nursing home setting.
Demonstrates an understanding of current Quality Measure Initiatives, including Value-Based Care.
A thorough understanding of anatomy, pathophysiology, and medical terminology is necessary to correctly code using CPT, ICD-10, and HCPCS Level II coding systems.
Experience with multiple EMR systems such as EPIC, Athena, Medent, Acumen, and Allscripts, preferred.
Working knowledge of HIPAA Privacy and Security Rules.
You accept that things change quickly and are willing to pivot quickly on priorities.
Demonstrated proficiency in computer skills, i.e., Microsoft Windows, Outlook, Excel, Word, PowerPoint, Internet browsers, Microsoft Teams.
Strong people skills and ability to build supportive relationships with providers.
Outstanding organizational skills and an ability to operate efficiently and independently.