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Clinical Documentation Specialist
Mercy Medical Center, Cedar Rapids, IA

Location: Cedar Rapids, Iowa
Work Setting: Hospital
Job Function:
HIM Specialist
Job Type:


The physician advisor will act as a liaison between the Medical Documentation Team (CDI), HIM, Business Office, other departments of the Revenue Cycle team, and the hospital and clinic medical staff to facilitate accurate and complete documentation. This includes documentation for coding and abstracting of clinical data, capture of severity, acuity, HCC, HAC, and risk of mortality, in addition to APC assignment. Review and recommendation of provider evaluation and management levels and procedures. The physician advisor helps facilitate training for physicians.

Job Description


 Reporting Relationships

Supervised By:

Manager, Clinical Documentation Improvement & Auditing

 Job Duties/Essential Functions


  • Work with the Medical Documentation Team (CDI) personnel on a routine basis to: review selected health records prebill, explain clinical issues that arise in chart review. In addition, the physician advisor will help develop clinically appropriate and compliant physician queries to further clarify documentation.
  • Educate individual physicians about ICD coding guidelines (e.g., co-morbid conditions, outpatient vs inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and APC assignments on their individual patient records.
  • Work with the Medical Documentation team to ensure that Epic appropriately supports the physician’s ability to document the clinical care provided.
  • As a subject matter expert, assist in the development of Medical Documentation (CDI) communications to further educate the medical providers.
  • Facilitate complete health record documentation to meet ministry-wide standards.
  • Assist Medical Documentation (CDI) team by communicating with documenting physicians as appropriate.
  • Utilize facility metrics regarding documentation performance to create and implement a documentation improvement plan for the facility and clinic.
  • Audit physician coders using set guidelines. Provide personalized feedback to physician coders based on individual audit results. Identify systemic errors across coders and provide group education to the physician coding team as indicated.
  • Audit the Optum coding tool to assure the tool is within compliance standards.
  • Review said compliance standards to assure they are up to date.
  • Audit coders using the Optum tool to understand why coders and providers are not agreeing with Optum recommendations. Provide said report out to the HIM Manager.
  • Onboard providers and clinics to the Optum coding tool.
  • Onboard physician coders.
  • Follows Mercy’s safety guidelines, carries out job-specific safety duties and responsibilities, and promptly reports any unsafe conditions, situations, incidents and injuries.



Required Qualifications

Knowledge, Skills and Abilities

  • Proficient in Microsoft Office products.
  • Proficient in operation of computer, calculator, filing systems, copy/fax machines and telephone system.
  • Excellent interpersonal skills.
  • Excellent written and verbal communication skills.
  • Excellent public relations and human relations – exemplifies The Mercy Touch.
  • Excellent organizational and time management skills.
  • Critical thinking, problem solving, and attention to detail skills.
  • Exhibits good judgement.
  • Handles confidential information with discretion and diplomacy.
  • Commitment to life-long learning, e.g. willingness to learn/upgrade skills related to duties.
  • Flexibility and dependability, works well with a wide variety of individuals and leadership styles.
  • Ability to work with minimal to no supervision.
  • Knowledge of Medicare Part A.
  • Familiar with Medicare Part B.
  • Understand and communicate differences between Medicare Part A and Part B Guidelines.
  • Knowledge of regulatory environment.

Professional Experience

  • Minimum two years acute care or equivalent clinical setting experience


    • Knowledge of CPT and ICD code
    • Experience in critical care


  Licensure, Certification, Registration

  • Certification as CPC, CCS-P required.
  • RHIA, RHIT certification preferred.
  • The department requires CDI certification within one year of hire, if not obtained at hire.

Education Qualifications



    • Associate’s degree in Health Information Management or related field


    • Bachelor of Science degree in Health Information Management or related field

Apply Online:

Posted: February 10, 2020 at 5:25 PM
Post ID: 47922

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