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Clinical Documentation Integrity Specialist, Remote - job 2 of 2

Aledade, a public benefit corporation, exists to empower the most transformational part of our health care landscape - independent primary care. We were founded in 2014, and since then, we've become the largest network of independent primary care in the country - helping practices, health centers and clinics deliver better care to their patients and thrive in value-based care.


We are searching for a Clinical Documentation Integrity Specialist (CDIS) to join the team. The person in this role will lead field and provider education and training related to complete and accurate diagnostic documentation and coding, in accordance with ICD-10 CM coding guidelines, internal protocols and CMS and payer guidelines. The CDIS will deliver tailored education at the national, market, practice, and individual provider-level; complete end-to-end workflow assessment and optimization; and perform chart reviews to identify specific opportunities for improved accuracy. There will be opportunity to travel periodically to practices as well as engage in remote work.  The CDIS must be detail-oriented, service-minded, possess strong verbal and written communication skills, and be fluent in (or willing and able to master) Google Suite tools.


Primary Duties:
  • Perform chart reviews to identify opportunities for better accuracy in clinical documentation and coding.  Evaluate and optimize end-to-end practice clinical documentation, billing and coding workflows. Develop and implement action plans to improve the completeness and accuracy of clinical documentation and coding.
  • Work directly with Aledade practices and providers on continuous improvement of complete and accurate documentation and diagnosis coding. Facilitate clinical documentation and coding communication amongst key internal and external stakeholders. Provide guidance to field staff and practices regarding general documentation and coding best practices and risk adjustment.
  • Deliver internal and external-facing education and training on clinical documentation and diagnosis coding to support value-based contracts.


Minimum Qualifications:
  • Essential to perform duties without CDI training.
  • Bachelor’s degree in a healthcare related field or equivalent work experience required.
  • At least 1 of the following: Current certification as a Certified Professional Coder (CPC), Certified Documentation Expert Outpatient (CDEO®) from AAPC, Certified Clinical Documentation Specialist-Outpatient (CCDS-O) from ACDIS.
  • 3+ years of recent, relevant work experience in CDI or 5+ years as a risk adjustment auditor; 3+ years RCM or billing experience.
  • Familiarity with anatomy and physiology, disease processes and medical terminology.
  • Thorough understanding of medical coding guidelines and regulations including compliance, reimbursement, and the impact of diagnosis documentation on risk adjustment payment models.
  • Subject matter expertise on the CMS HCC Risk Adjustment program, methodology, and impact to value-based contracts.
  • Ability to identify and communicate opportunities to improve documentation and diagnosis capture for accurate risk adjustment coding.
  • Experience working directly with physician practices and individual providers to achieve demonstrable improvement in increasing the accuracy and completeness of documentation and diagnosis coding.


Preferred Key Skills and Abilities:
  • Successful track record in outpatient coding and billing through previous experience.
  • Self-directed and solution oriented.
  • Strong understanding of value-based care principles, particularly as they relate to the impact of clinical documentation and coding on risk adjustment payment models in value-based contracts.
  • Strong understanding of outpatient coding and billing.
  • Solution-oriented individual who can execute tactical continuous quality improvement work to deliver results in value-based contracts.
  • Excellent communicator who can articulate the impact of documentation and diagnosis initiatives to Aledade ACO member practices and their key staff (e.g., office managers, practice billers, etc.), and internally within the company. 
  • Ability to work collaboratively across Aledade clinical and non-clinical teams to gain buy-in and implement key documentation improvement initiatives.
  • References demonstrating high degree of integrity and professional accountability.


Who We Are:

Aledade, a public benefit corporation, exists to empower the most transformational part of our health care landscape - independent primary care. We were founded in 2014, and since then, we've become the largest network of independent primary care in the country - helping practices, health centers and clinics deliver better care to their patients and thrive in value-based care. Additionally, by creating value-based contracts across a wide variety of payers, we aim to flip the script on the traditional fee-for-service model. Our work strengthens continuity of care, aligns incentives, and ensures primary care physicians are paid for what they do best - keeping patients healthy. If you want to help create a health care system that is good for patients, good for practices and good for society - and if you're eager to join a collaborative, inclusive and remote-first culture - you've come to the right place.


What Does This Mean for You?

At Aledade, you will be part of a creative culture that is driven by a passion for tackling complex issues with respect, open-mindedness and a desire to learn. You will collaborate with team members who bring a wide range of experiences, interests, backgrounds, beliefs and achievements to their work - and who are all united by a shared passion for public health and a commitment to the Aledade mission.


In addition to time off to support work-life balance and enjoyment, we offer the following comprehensive benefits package designed for the overall well-being of our team members:

Flexible work schedules and the ability to work remotely are available for many roles

Health, dental and vision insurance paid up to 80% for employees, dependents, and domestic partners Robust time off plan 21 days of PTO in your first year 2 Paid Volunteer Days & 11 paid holidays

12 weeks paid Parental Leave for all new parents

6 weeks paid sabbatical after 6 years of service

Educational Assistant Program & Clinical Employee Reimbursement Program

401(K) with up to 4% match

Stock options

And much more!


At Aledade, we don’t just accept differences, we celebrate them!   We strive to attract, develop, and retain highly qualified individuals representing the diverse communities where we live and work. Aledade is committed to creating a diverse environment and is proud to be an equal opportunity employer. Employment policies and decisions at Aledade are based on merit, qualifications, performance, and business needs. All qualified candidates will receive consideration for employment without regard to age, race, color, national origin, gender (including pregnancy, childbirth or medical conditions related to pregnancy or childbirth), gender identity or expression, religion, physical or mental disability, medical condition, legally protected genetic information, marital status, veteran status, or sexual orientation.


Privacy Policy: By applying for this job, you agree to Aledade's Applicant Privacy Policy available at  https://www.aledade.com/privacy-policy-applicants

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What You Should Know About Clinical Documentation Integrity Specialist, Remote, Aledade

Join Aledade as a Clinical Documentation Integrity Specialist (CDIS) and be an integral part of transforming healthcare! In this fully remote role, you will empower independent primary care practices by leading comprehensive education and training initiatives focused on achieving accurate diagnostic documentation and coding. As the go-to expert in ICD-10 CM coding guidelines, you'll dive into the intricacies of chart reviews, optimizing workflows, and delivering tailored education across various levels—from national to individual providers. Your attention to detail and strong communication skills will ensure you're effectively guiding practices through the nuances of clinical documentation, enhancing both their operations and patient care. You’ll collaborate closely with our dedicated team to uphold the quality of documentation that drives value-based care. Your journey in this rewarding position encompasses hands-on experience, traveling to practices for in-field training, and working remotely in a supportive and inclusive culture. With a Bachelor’s in a healthcare-related field and a certification like CPC or CCDS-O, along with relevant work experience, you're primed for success in this role at Aledade. Ready to make a difference in the world of health care? We can't wait to meet you!

Frequently Asked Questions (FAQs) for Clinical Documentation Integrity Specialist, Remote Role at Aledade
What are the primary responsibilities of a Clinical Documentation Integrity Specialist at Aledade?

As a Clinical Documentation Integrity Specialist at Aledade, your main responsibilities will include performing thorough chart reviews to enhance the accuracy of clinical documentation and coding. You'll develop action plans to improve workflows, facilitate education and training for practices on best documentation practices, and communicate vital guidelines to various stakeholders. This role is essential in helping our network of independent practices thrive in a value-based care system.

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What qualifications do I need to become a Clinical Documentation Integrity Specialist at Aledade?

To qualify for the Clinical Documentation Integrity Specialist position at Aledade, you must have a Bachelor’s degree in a healthcare-related field or equivalent experience. Essential certifications include options like Certified Professional Coder (CPC) or Certified Clinical Documentation Specialist (CCDS-O). Additionally, you should have at least three years of experience in CDI or risk adjustment auditing, alongside a deep understanding of medical coding guidelines.

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How does Aledade support the continuous improvement of clinical documentation?

At Aledade, the Clinical Documentation Integrity Specialist plays a crucial role in fostering continuous improvement of clinical documentation. Through tailored education, detailed chart reviews, and effective communication, you will work directly with practices to identify areas for enhancement. You’ll develop strategies that ensure documentation aligns with the rigorous requirements of value-based contracts, enabling practices to improve patient outcomes while achieving higher accuracy in coding.

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What skills are crucial for success as a Clinical Documentation Integrity Specialist at Aledade?

To excel as a Clinical Documentation Integrity Specialist at Aledade, you should possess strong analytical skills to evaluate documentation practices critically. Excellent verbal and written communication abilities are essential for educating providers. Familiarity with Google Suite tools is beneficial, and a solid understanding of value-based care principles will greatly support your efforts in enhancing practices' documentation quality.

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Can I work remotely as a Clinical Documentation Integrity Specialist at Aledade, and what does the work culture look like?

Yes, the Clinical Documentation Integrity Specialist role at Aledade is remote, allowing for flexible work arrangements. Our work culture is collaborative, inclusive, and deeply committed to public health. You'll join a team that values diversity and empowers its members to tackle complex challenges together, fostering an environment where everyone can thrive.

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Common Interview Questions for Clinical Documentation Integrity Specialist, Remote
How do you approach chart reviews to ensure accuracy in clinical documentation?

In approaching chart reviews, I start with a comprehensive understanding of coding guidelines and medical terminology. I meticulously analyze the documentation against established benchmarks and identify potential discrepancies. By providing grounded, constructive feedback to providers, I can help them understand areas needing improvement and the significance of accurate documentation for risk adjustment.

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Can you describe your experience with ICD-10 CM coding and how it applies to this role?

I have extensive experience with ICD-10 CM coding, having navigated its complexities throughout my career. This experience enables me to evaluate documentation comprehensively and ensure compliance with coding standards. I leverage this knowledge to educate providers and teams on coding best practices and the implications for reimbursements in a value-based care environment.

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What strategies would you implement to train providers on clinical documentation?

To train providers effectively, I would first conduct needs assessments to understand their current level of documentation practices. Then, I would develop customized training sessions that incorporate both theoretical knowledge and practical applications. Engagement methods such as hands-on workshops, detailed case studies, and ongoing support would be crucial for reinforcing these concepts and encouraging continuous improvement.

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How do you stay updated on the latest regulations and guidelines in coding and documentation?

I prioritize staying current with coding regulations by subscribing to relevant professional organizations, attending webinars, and participating in ongoing training courses. I also follow industry publications and forums to remain engaged with both changes in regulations and trends in clinical documentation integrity, ensuring that my team benefits from the most updated information.

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How would you handle conflicts when communicating documentation requirements to providers?

In handling conflicts, I believe in addressing issues openly and empathetically. First, I’d listen to the provider’s concerns to understand their perspective. Then, I would clearly outline the rationale behind the documentation requirements, emphasizing how compliance benefits their practice. Building rapport and trust is essential, so I would focus on collaborative problem-solving to find the best path forward.

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What is your experience working with interdisciplinary teams in a healthcare setting?

I have collaborated closely with interdisciplinary teams, including clinicians and administrative staff, in my previous roles. Effective communication and understanding the unique contributions of each member are crucial in driving successful documentation initiatives. I prioritize creating open dialogue and fostering a collaborative environment to ensure that everyone is aligned with our goals.

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Can you provide an example of a successful initiative you implemented to improve documentation practices?

One successful initiative involved creating a targeted training program for outpatient practices that I developed after identifying a gap in documentation accuracy related to specific diagnoses. I tailored the training to address these challenges and provided ongoing support, which resulted in a significant increase in documentation accuracy and improved coding compliance for those practices.

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What are some common challenges you have faced in your past roles, and how did you overcome them?

Common challenges I've faced include resistance to change from providers and discrepancies in documentation. To overcome these, I focused on building trust through open communication and presenting data that highlighted the importance of accurate documentation. I also provided supportive resources and strategies, which helped to foster a more receptive environment for change.

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In your view, what impact does clinical documentation have on patient care?

Good clinical documentation is pivotal in ensuring patient care quality. It directly affects treatment planning, care continuity, and reimbursement. Accurate documentation helps all team members access reliable patient information, facilitating better clinical decisions and ultimately enhancing patient outcomes. It’s the foundation that supports effective risk adjustment and value-based care initiatives.

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How do you prioritize your workflow when managing multiple documentation projects?

I prioritize my workflow by establishing clear benchmarks for each project based on urgency and impact. I use project management tools to track tasks and deadlines, ensuring everything stays organized. Regular communication with stakeholders helps me identify potential roadblocks early, allowing me to adjust my priorities as needed while ensuring each project receives the attention it deserves.

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At the heart of the Aledade model is the simple, but radical, idea that Aledade only succeeds when partner practices succeed in lowering costs to payers through better care for patients. By keeping patients and their healthcare providers at the ce...

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Full-time, remote
DATE POSTED
January 28, 2025

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