Outpatient Clinical Documentation Specialist

📋 Description

• • The Outpatient Clinical Documentation Specialist plays a critical role in ensuring accurate risk adjustment capture by reviewing medical records for clinical validity and completeness, directly impacting reimbursement, quality reporting, and patient outcomes in value-based care arrangements.
• • Day-to-day responsibilities include performing pre-visit chart reviews, identifying clinical indicators for high-risk conditions, creating compliant CDI queries, engaging with providers to improve documentation, tracking trends in documentation gaps, and supporting education initiatives to enhance clinical documentation integrity across specialties.
• • BMC Software, Inc. operates in the healthcare technology space, supporting organizations like WellSense in managing risk adjustment and clinical documentation improvement programs; this role sits within the Clinical Documentation team, contributing to compliant, accurate, and clinically meaningful documentation that supports value-based care goals.
• • In this role, the specialist will deepen expertise in risk adjustment methodologies (including DxCG and HCC), refine clinical query writing skills, strengthen provider collaboration abilities, and gain experience in tracking and reporting CDI outcomes—positioning them for advancement in clinical documentation, coding, or population health leadership.