The Clinical Documentation Specialist (CDS) performs documentation and coding audits, evaluates compliance, and delivers education across Kahtnuht’ana Development Corporation (KDC)’s clinical and operational teams. This role supports all awarded proposals, Indian Health Service (IHS) contracts, and Tribal health system requirements by ensuring documentation integrity, compliant coding practices, and alignment with federal, state, and Tribal regulations.
PRINCIPAL ACTIVITIES & RESPONSIBILITIES
- Establish and maintain a formal documentation and coding audit program.
- Conduct routine and targeted audits to validate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD 10 CM), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and Procedure Coding System (PCS) code accuracy.
- Perform prospective and retrospective reviews to ensure medical necessity and documentation sufficiency.
- Analyze audit findings; prepare reports; deliver provider specific education.
- Develop follow up audits and documentation improvement plans.
- Provide coding guidance across inpatient, outpatient, professional, surgical, home health, and ancillary services.
- Design and deliver training programs for compliant coding and billing aligned with regulatory requirements.
- Evaluate vendor training materials for applicability across KDC operations and Tribal/IHS contract environments.
- Maintain current knowledge of federal/state regulatory changes; update training materials accordingly.
- Participate in committees, operational initiatives, and compliance reviews.
- Support documentation improvement efforts tied to grants, proposals, and contract deliverables.
- Ensure documentation practices align with Centers for Medicare & Medicaid Services (CMS), Health Resources and Services Administration (HRSA), and Indian Health Service (IHS) requirements.
- Collaborate with Revenue Cycle and Quality teams to reduce denials related to documentation insufficiency and medical necessity.
- Assist in preparing documentation components for Prospective Payment System (PPS), All Inclusive Rate (AIR), and wrap around reimbursement submissions.
- Perform additional duties as assigned.
- Travel to customer site periodically as needed (up to 40%).
QUALIFICATIONS
- Associate or Bachelor’s degree in HIM preferred.
- Minimum 5 years acute care coding experience.
- Experience in adult education or training preferred.
- Required certification: Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Certified Coding Specialist – Physician based (CCS P), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Registered Health Information Administrator (RHIA).
- Experience with Tribal health systems, Indian Health Service (IHS), or Federally Qualified Health Center (FQHC) environments preferred.
- Knowledge of documentation requirements for value based care, Alternative Payment Models (APMs), and federal contract deliverables.
- Proficiency with Electronic Health Record (EHR) systems used in Tribal/IHS settings (e.g., RPMS, Cerner, Epic).
PHYSICAL REQUIREMENTS
Physical job requirements encompass a range of activities that may be necessary for various roles. These can include, but are not limited to:
- Lifting and Carrying: Ability to lift and transport objects up to 25 pounds occasionally.
- Standing and Walking: Position may require prolonged periods of standing or walking.
- Bending and Stooping: Ability to bend, stoop, and crouch as needed.
- Reaching and Pushing/Pulling: Ability to reach for items and move office equipment as necessary.
- Sitting: Ability to sit for extended periods while performing administrative and computer-based work.
EQUAL OPPORTUNITY AND TRIBAL PREFERENCE STATEMENT
Kahtnuht’ana Development Corporation and the Kahtnu Family of Companies is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other protected status.
In accordance with applicable federal law, preference will be given to qualified Kenaitze Indian Tribe members.
Requires 5 years of acute care coding experience and one listed coding or health information credential; HIM degree and adult training experience preferred. EHR proficiency required.
Key Responsibilities
- auditing documentation
- guiding coding
- delivering training
Skills & Tools
ICD-10-CM, CPT, HCPCS, PCS, Electronic Health Record (EHR), RPMS, Cerner, Epic
Job Details
- Category: Healthcare Services - Allied Health
- Seniority: Senior Level
- Commitment: Full Time
- Workplace: Remote — United States
- Salary: USD 67,000 – 119,000 / year
- Languages: English
About KAHTNUHTANA DEVELOPMENT CORPORATION
A development corporation supporting Tribal healthcare systems, contracts, and community services. — Industry: Healthcare