Job Description

The Clinical Documentation & Coding Specialist (CDCS) plays a critical role in ensuring accurate and comprehensive documentation within Alteas Health’s clinical and administrative systems. This position focuses on improving the quality of patient care documentation, optimizing reimbursement, and maintaining compliance with healthcare regulations and coding standards. The ideal candidate will work collaboratively with physicians, healthcare providers, and administrative staff to review and enhance clinical documentation and coding accuracy. As a subject matter expert, this role involves conducting audits, providing education, and implementing process improvements that promote best practices in documentation and coding. 

***Alteas has openings for this opportunity in Illinois, Kansas, Wisconsin and Missouri***

Alteas Health is dedicated to contributing to the success of our T.E.A.M by providing: 

• $2,000 Sign-On Bonus

• Competitive Salary 

• Travel Allowance, as needed 

• Licensure Reimbursement

• Continuing Education

• Mentoring programs 

• 401k

• Insurance Benefits 

• Employer Paid Life Insurance 

• FSA or LPFSA 

• HSA options 

• Short-Term Disability, Long-Term Disability, Critical Illness, Accident Coverage & Hospital Indemnity

Key Responsibilities:

• Review patient medical records to ensure documentation is accurate, comprehensive, and compliant with healthcare regulations and standards. 

• Collaborate with physicians, healthcare providers and clinical staff to clarify and improve documentation practices. 

• Promote best practices in clinical documentation to ensure diagnoses, procedures, and treatment plans are fully supported. 

• Identify and address gaps in documentation quality using CDI systems and methodologies. 

• Educate clinical staff on accurate documentation’s role in improving patient care and ensuring proper reimbursement. 

• Conduct regular audits of clinical documentation and coding for completeness, accuracy, and compliance with federal, state, and payer-specific regulations. 

• Assign and validate ICD-10-CM, CPT, and HCPCS codes to diagnoses, procedures and medical services based on clinical documentation. 

• Ensure compliance with coding standards and payer-specific requirements, including Medicare, Medicaid and private insurance guidelines. 

• Track and analyze documentation and coding trends, providing feedback and recommending improvements to enhance quality and accuracy. 

• Provide ongoing training and support to clinical and administrative staff on documentation integrity, coding procedures and compliance. 

• Maintain a thorough understanding of updates to coding standards and industry regulations (e.g., ICD-10, CPT, HCPCS, HIPAA, CMS) and ensure organizational adherence. 

• Assist in identifying areas for process improvement in documentation practices and coding accuracy. 

• Work closely with clinical and administrative teams to promote accurate and thorough documentation practices. 

• Serve as a subject matter expert, advising on best practices and process improvements in clinical documentation and coding. 

Qualifications:

• Certified Clinical Documentation Integrity Specialist (CDIS) or equivalent certification required. 

• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification required. 

• 3-5 years of experience in clinical documentation improvement and medical coding in a healthcare setting. 

• Proven experience with ICD-10, CPT, and HCPCS coding systems. 

• Proficiency with Electronic Health Record (EHR) systems and coding software. 

• Familiarity with healthcare compliance regulations, including HIPAA and payer-specific guidelines. 

Preferred Requirements: 

• 2+ years of experience with SNF, LTC, and Acute care settings

• 2+ years of experience with Cardiology or Pulmonary care 

• Associate's or Bachelor's degree in Health Information Management, Nursing, or a related field

• Willingness to travel for education and training, as required 

Professional Skills: 

• Compassionate Resilience

• Integrity and Humility

• Innovation

• Demonstrate good judgment and problem-solving.

• Effective planning, communication, and organizational skills

Alteas Health is a rapidly growing, innovative dynamic company looking for a compassionate, resilient, self-starting, skilled healthcare professional who thrives in a fast paced, ever-changing environment to join our clinical team. Focused on advancing the delivery of patient care by empowering the growth and success of our employees and valued partnerships; Alteas Health is a proven leader in providing sub-specialty care to an underserved population throughout Illinois, Indiana, Florida, Kansas, Michigan, Missouri, Ohio and Wisconsin.

Focused on advancing the delivery of patient care by empowering the growth and success of our employees and valued partnerships .

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