Clinical Documentation Improvement Specialist
Description
SUMMARY
At ZoomCare we are working hard to make healthcare easy. Our mission is to deliver innovative, high-quality, convenient healthcare when patients need it. We offer same-day, no-wait visits in urgent care, primary care, and specialty care and we're expanding from our roots in the Pacific Northwest to new markets. We hope you will apply to become part of our dedicated, fast-moving team of superstars!
ZoomCare is seeking a Clinical Documentation Improvement Specialist
to join our team! The Clinical Documentation Improvement (CDI) Specialist is responsible for reviewing outpatient clinical documentation to ensure accuracy, completeness, and compliance with coding and regulatory requirements. This role focuses on provider education and serves as a liaison between clinical and coding departments to optimize documentation practices.
SCHEDULE AND TRAINING
- Monday - Friday
- Hybrid Remote
- Depending on the position and associated requirements, there may be additional mandatory training requirements that are outside of your scheduled shift.
ESSENTIAL FUNCTIONS
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Represent our values: Awesome, Creative, Respectful, Team Players, Get it Done.
- Review outpatient clinical documentation to identify gaps in specificity, clarity, and completeness, ensuring alignment with coding and regulatory requirements.
- Collaborate with providers to improve documentation practices through real-time feedback, one-on-one discussions, and follow-up on identified deficiencies.
- Educate providers on documentation standards that support accurate ICD-10-CM, CPT, and HCPCS code assignment and appropriate reimbursement.
- Work closely with coding staff to resolve documentation discrepancies, respond to coding queries, and ensure documentation supports code selection.
- Develop, implement, and maintain provider education programs and materials focused on clinical documentation improvement (CDI) best practices.
- Monitor and track CDI program metrics and key performance indicators (KPIs), including query response rates, documentation quality trends, and impact on case mix index (CMI).
- Participate in regular internal audits and compliance reviews to assess documentation accuracy and adherence to established guidelines.
- Provide data-driven feedback and recommendations to leadership on documentation trends and opportunities for performance improvement.
- Assist in the development and maintenance of facility-specific documentation tools, templates, and resources to support provider compliance and workflow efficiency.
- Stay current on industry standards, regulatory updates, and coding guidelines that impact clinical documentation and reimbursement.
- Other duties as assigned.
QUALIFICATIONS
- Bachelor’s degree in Nursing, Health Information Management, or a related healthcare field required; candidates with 15+ years of coding experience in an outpatient healthcare setting may be considered in lieu of a degree.
- 5+ years of coding experience in an outpatient setting.
- Must reside in the Portland/Vancouver area and be able to travel to multiple clinics regularly, approximately 10% of the time.
- Current coding certification required through AHIMA or AAPC (e.g., CCS, CPC, COC, or equivalent) or Registered Health Information Administrator (RHIA).
- Extensive knowledge of ICD-10-CM, CPT, and HCPCS coding systems, with proven application in outpatient clinical documentation and billing.
- Demonstrated experience in provider education and clinical documentation training, including developing and delivering educational materials.
- Strong understanding of medical terminology, anatomy, physiology, and common disease processes necessary for accurate code assignment and documentation review.
- Proficiency in working with electronic health record (EHR) systems and documentation tools; experience with Epic, Cerner, or equivalent platforms preferred.
- Knowledge of quality reporting programs, including HEDIS, MIPS, and other value-based care initiatives, and how documentation impacts performance measures.
- Excellent verbal and written communication skills, with the ability to engage and educate providers, collaborate with coding professionals, and convey clinical concepts clearly.
- Strong critical thinking, analytical, and problem-solving skills with high attention to detail.
- Ability to manage multiple priorities, meet deadlines, and work independently in a fast-paced clinical or administrative environment.
COMPENSATION PACKAGE
- Medical, Dental, Vision benefits
- 401K with employer match
- Paid Time Off, Paid Holidays, Paid Parental Leave, Sabbatical Program
- Hourly Pay Rate: $42.00 - $48.00 DOE
- Other Compensation: May be eligible for other compensation such as bonuses
WORKING CONDITIONS
- Project timelines and work volume/deadlines may often require more than your scheduled hours per week or work outside of regular business hours to complete essential duties of this job.
- Ability to work at a computer/workstation for prolonged periods of time.
- Close and distance vision and ability to adjust focus.
- Seeing, hearing, speaking, and writing clearly in order to effectively communicate with others.
- Exposure to sensitive and confidential information.
- Occasional reaching and lifting of small objects and operating office equipment.
- Must reside in the Portland/Vancouver area and be able to travel to multiple clinics regularly, approximately 10% of the time.