Cano Health
Job Summary
Full‑time Clinical Documentation Improvement Specialist (CDIS) ensuring accurate, complete clinical documentation that reflects patient severity and supports accurate coding of diagnoses for all patients. This role focuses on optimizing documentation to improve risk‑adjustment data and ensure compliance with CMS guidelines.
Essential Duties & Responsibilities
Review clinical documentation and medical records for accuracy, completeness, and compliance with Medicare Risk Adjustment coding requirements.
Work with physicians, providers, and healthcare teams to clarify documentation and improve the specificity of diagnoses to reflect the patient’s clinical condition.
Ensure accurate coding of all diagnoses, including chronic conditions and comorbidities, to support Medicare Risk Adjustment (HCC) and maximize appropriate reimbursement.
Analyze and abstract relevant clinical data from patient records and assign ICD‑10‑CM codes appropriately.
Monitor and track documentation improvement metrics, providing feedback and recommendations to physicians and healthcare teams.
Conduct regular chart audits and provide education and training to clinical staff on best practices for documentation and coding.
Stay current with CMS regulations, ICD‑10‑CM coding updates, and risk adjustment methodologies to ensure compliance and optimal risk score capture.
Participate in multidisciplinary team meetings and collaborate with quality assurance, coding, and operations teams to improve documentation workflows.
Identify opportunities to improve documentation processes and contribute to the development of internal training programs and tools.
Best Practices
Attention to detail and accuracy in clinical documentation review.
Strong understanding of Medicare Risk Adjustment (HCC) and its impact on reimbursement.
Ability to work independently, prioritize tasks, and manage multiple projects effectively.
Excellent interpersonal and communication skills for interacting with medical professionals, coders, and stakeholders.
Education & Experience
Associate’s or Bachelor’s degree in healthcare, nursing, or a related field.
Five (5) or more years as a coding and billing specialist (ICD‑10, CPT, and HCPCS).
Advanced analytical and data manipulation skills.
AAPC certifications (CRC, CDEO, CPMA, etc.) and new hires must be CPC Certified from AAPC or AHIMA equivalent.
Minimum two (2) years as a Clinical Documentation Improvement Specialist or similar role, inclusive of coding and billing auditing or risk adjustment coding.
Computer proficiency (MS‑Outlook, Word, Excel, PowerPoint).
Bi‑lingual (English/Spanish) required.
Knowledge, Skills & Proficiencies
Advanced coding background, medical terminology, anatomy, pharmacology, and disease management knowledge.
Strong written and verbal communication skills.
Excellent time‑management, organization, and critical‑thinking abilities.
Strong collaboration, relationship‑building, and process‑management skills.
High attention to detail and ability to learn new tasks and concepts.
Commitment to integrity, accountability, and continuous improvement.
Physical Requirements The position involves using a computer and making phone calls for extended periods, standing, sitting, walking, and occasionally climbing. The employee may be required to lift up to 50 lbs and work extended or flexible hours, including weekends, as needed. Reasonable accommodations may be made for individuals with disabilities.
Work Conditions & Travel The role may be performed remotely or from company offices. Occasional out‑of‑state travel may be required based on business needs. Up to 90% travel may be expected; travel requirements can include regional trips.
Tools & Equipment Standard computer peripherals, customized software applications, and usual office equipment.
Disclaimer This description lists general duties and may not be exhaustive. The company reserves the right to reassign duties or responsibilities as needed. Cano Health is an equal‑opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.
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Essential Duties & Responsibilities
Review clinical documentation and medical records for accuracy, completeness, and compliance with Medicare Risk Adjustment coding requirements.
Work with physicians, providers, and healthcare teams to clarify documentation and improve the specificity of diagnoses to reflect the patient’s clinical condition.
Ensure accurate coding of all diagnoses, including chronic conditions and comorbidities, to support Medicare Risk Adjustment (HCC) and maximize appropriate reimbursement.
Analyze and abstract relevant clinical data from patient records and assign ICD‑10‑CM codes appropriately.
Monitor and track documentation improvement metrics, providing feedback and recommendations to physicians and healthcare teams.
Conduct regular chart audits and provide education and training to clinical staff on best practices for documentation and coding.
Stay current with CMS regulations, ICD‑10‑CM coding updates, and risk adjustment methodologies to ensure compliance and optimal risk score capture.
Participate in multidisciplinary team meetings and collaborate with quality assurance, coding, and operations teams to improve documentation workflows.
Identify opportunities to improve documentation processes and contribute to the development of internal training programs and tools.
Best Practices
Attention to detail and accuracy in clinical documentation review.
Strong understanding of Medicare Risk Adjustment (HCC) and its impact on reimbursement.
Ability to work independently, prioritize tasks, and manage multiple projects effectively.
Excellent interpersonal and communication skills for interacting with medical professionals, coders, and stakeholders.
Education & Experience
Associate’s or Bachelor’s degree in healthcare, nursing, or a related field.
Five (5) or more years as a coding and billing specialist (ICD‑10, CPT, and HCPCS).
Advanced analytical and data manipulation skills.
AAPC certifications (CRC, CDEO, CPMA, etc.) and new hires must be CPC Certified from AAPC or AHIMA equivalent.
Minimum two (2) years as a Clinical Documentation Improvement Specialist or similar role, inclusive of coding and billing auditing or risk adjustment coding.
Computer proficiency (MS‑Outlook, Word, Excel, PowerPoint).
Bi‑lingual (English/Spanish) required.
Knowledge, Skills & Proficiencies
Advanced coding background, medical terminology, anatomy, pharmacology, and disease management knowledge.
Strong written and verbal communication skills.
Excellent time‑management, organization, and critical‑thinking abilities.
Strong collaboration, relationship‑building, and process‑management skills.
High attention to detail and ability to learn new tasks and concepts.
Commitment to integrity, accountability, and continuous improvement.
Physical Requirements The position involves using a computer and making phone calls for extended periods, standing, sitting, walking, and occasionally climbing. The employee may be required to lift up to 50 lbs and work extended or flexible hours, including weekends, as needed. Reasonable accommodations may be made for individuals with disabilities.
Work Conditions & Travel The role may be performed remotely or from company offices. Occasional out‑of‑state travel may be required based on business needs. Up to 90% travel may be expected; travel requirements can include regional trips.
Tools & Equipment Standard computer peripherals, customized software applications, and usual office equipment.
Disclaimer This description lists general duties and may not be exhaustive. The company reserves the right to reassign duties or responsibilities as needed. Cano Health is an equal‑opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.
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