Senior Clinical Documentation Improvement (CDI) Specialist

Department:

Reports To:

Summary:

The Senior Claims Processing Specialist is responsible for overseeing all aspects of charge creation and capture, ensuring accurate and compliant billing practices. This role also acts as liaison for clinical areas and revenue cycle (physicians, nurses, and other clinical staff) on proper documentation, coding, and billing procedures. The Senior Specialist plays a critical role in maximizing revenue integrity, minimizing denials, and ensuring compliance with payer regulations.

Key Responsibilities:

Charge Creation and Capture Oversight

• Oversee the process of charge creation, ensuring accurate and timely capture of all billable services.
• Review encounter documentation (e.g., progress notes, orders, procedures) to verify that charges are supported and appropriately coded.
• Identify and correct any errors or omissions in charge capture.
• Monitor charge lag and implement strategies to reduce delays in billing.
• Ensure that all charges are compliant with coding guidelines (CPT, HCPCS, ICD-10) and payer regulations.

Charge Master Maintenance

• Participate in the maintenance and updating of the charge master (CDM), if applicable.
• Ensure that the CDM is accurate and reflects current coding guidelines and payer requirements.
• Collaborate with other departments (e.g., finance, IT) to implement CDM changes.

Liaison Activities

• Liaise with clinical teams (physicians, nurses, etc.) to understand clinical workflows and documentation practices, ensuring accurate charge capture.
• Collaborate with revenue cycle teams (billing, coding, AR) to resolve claim issues and improve overall revenue cycle performance

Audits

• Conduct regular audits of documentation and billing practices to identify areas for improvement.
• Develop and implement corrective action plans to address identified deficiencies.
• Ensure compliance with all applicable coding and billing regulations.

Denial Management

• Analyze claim denials related to coding or documentation issues.
• Identify root causes of denials and implement strategies to prevent recurrence.
• Work with billing and coding staff to appeal denied claims.

Reporting and Analysis

• Prepare reports on charge capture rates and accuracy.
• Analyze data to identify trends and patterns in coding and billing practices.
• Recommend process improvements based on data analysis.

Team Leadership and Mentorship

• Serve as a mentor and resource for junior claims processing staff.
• Provide guidance and support to the team on complex coding and billing issues.
• Assist in training new team members on charge capture procedures.

Qualifications, Experience & Skills

• Any Bachelors degree or a related field preferred
• Minimum of 3-5 years of experience in medical coding, billing, or charge capture.
• Knowledge of medical coding and billing regulations.
• Excellent communication and interpersonal skills.
• Strong analytical and problem-solving abilities.
• Ability to work independently and as part of a team.
• Excellent organizational and time-management skills.
• Proficiency in using billing software and Microsoft Office Suite.

Preferred

• Experience with EPIC preferred but not mandatory.
• Both Hospital and Professional billing experience preferred
• Flexible to work from Office all 5 days in the week

Additional Details : -

• Charge Entry experience is relevant