CLINICAL DOCUMENTATION IMPROVEMENT SPECIALIST

El Centro Regional Medical Center • El Centro, CA

94d • $30 - $49

About The Position

The Clinical Documentation Improvement Specialist (CDIS) performs concurrent and retrospective reviews of medical records for opportunities to improve physician documentation. The CDIS position collaborates extensively with physicians to ensure documentation accurately, ethically, and compliantly reflects, captures, and reports patient severity-of-illness, risk of mortality and resource utilization using accepted coding nosologies and Diagnosis-Related Group (DRG) methodologies. Issues concurrent and retrospective physician queries, and interacts with the medical staff and other healthcare professionals in an effort to ensure complete and accurate documentation of the patient's clinical picture and the treatment provided. The CDIS acts as a liaison between case management, coding professionals and the medical/clinical staff regarding appropriate documentation and the query process.

Requirements

• Registered Nurse by the State of California, or Foreign Medical Graduate recognized by the Medical Board of California.
• Certified Coding Specialist (CCS) within 24 months of hire/transfer.
• CDI certification (CDIP/CCDS) within 27 months of hire/transfer.
• Certified Coding Specialist (CCS) through the American Health Information Management Association within 24 months of hire/transfer.
• Certified Clinical Documentation Specialist (CCDS) through the Association of Clinical Documentation Improvement Specialist (ACDIS) required within 27 months of hire/transfer.
• Certified Documentation Improvement Practitioner (CDIP) through the American Health Information Management Association (AHIMA) required within 27 months of hire/transfer.

Responsibilities

• Perform concurrent and retrospective reviews of medical records.
• Collaborate with physicians to improve documentation.
• Ensure documentation reflects patient severity-of-illness and risk of mortality.
• Issue physician queries for documentation improvement.
• Interact with medical staff to ensure accurate documentation.
• Act as a liaison between case management, coding professionals, and medical staff.

What This Job Offers

• Job Type: Full-time
• Industry: Merchant Wholesalers, Durable Goods