About The Position
The CDI Specialist is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the specificity of the physicians’ clinical documentation. This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff. Involved with educational activities to maintain up-to-date information on Medicare, ICD-10, and CPT coding, and documentation guidelines. Active participation in team meetings by providing recommendations on query structure, process, and workflow. Responds to coding denials with clinical justifications and coding conventions. Maintain confidentiality of information acquired pertaining to patients, physicians, associates, and adheres to HIPAA regulations. Keep the CDI team and HIM Manager or Director informed of workflow status and potential backlog issues. USC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability, or any other characteristic protected by law or USC policy. USC observes affirmative action obligations consistent with state and federal law. USC will consider for employment all qualified applicants with criminal records in a manner consistent with applicable laws and regulations, including the Los Angeles County Fair Chance Ordinance for employers and the Fair Chance Initiative for Hiring Ordinance, and with due consideration for patient and student safety. Please refer to the Background Screening Policy Appendix D for specific employment screen implications for the position for which you are applying. We provide reasonable accommodations to applicants and employees with disabilities. Applicants with questions about access or requiring a reasonable accommodation for any part of the application or hiring process should contact USC Human Resources by phone at (213) 821-8100, or by email at [email protected]. Inquiries will be treated as confidential to the extent permitted by law. Notice of Non-discrimination Employment Equity Read USC’s Clery Act Annual Security Report USC is a smoke-free environment Digital Accessibility If you are a current USC employee, please apply to this USC job posting in Workday by copying and pasting this link into your browser: https://wd5.myworkday.com/usc/d/inst/1$9925/9925$141553.htmld Keck Medicine of USC is the University of Southern California’s medical enterprise, one of only two university-based medical systems in the Los Angeles area. Keck Medicine combines academic excellence, world-class research and state-of-the-art facilities to provide highly specialized care for some of the most acute patients in the country. Our internationally renowned physicians and scientists provide world-class patient care at Keck Hospital of USC, USC Norris Cancer Hospital, USC Verdugo Hills Hospital, USC Arcadia Hospital and more than 100 unique clinics in Los Angeles, Orange, Kern, Tulare and Ventura counties. Keck Medical Center of USC, which includes Keck Hospital and USC Norris Cancer Hospital, is among the top 50 hospitals in the country in 8 specialties, as well as the top three hospitals in metro Los Angeles and top 10 hospitals in California, according to U.S. News & World Report’s 2024-25 Best Hospitals rankings. Application Help & Benefits If you need help during the application process, see our application help. For more information about our benefits, see What We Offer. Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit!
Requirements
- Graduate from a program of nursing, BSN, Health Information Management RHIT, RHIA, or foreign medical doctorate degree strongly preferred.
- Accredited college course work in human anatomy and/or physiology, medical terminology, and disease process is required.
- Competent with Windows based software programs.
- Extensive knowledge of ICD-10 CM and ICD-10-PCS coding, sequencing, and documentation guidelines skills and working knowledge of the AHA Coding Clinic preferred with experience in CPT/HCPCS for hospital and/or clinic records.
- Initiate appropriate clinical documentation querying to acquire or clarify necessary medical record documentation needed to facilitate accurate and complete coding.
- Demonstrate critical thinking, problem solving and deductive reasoning skills.
- Demonstrate effective verbal and written communication skills.
- Able to compose coding appeals based on documentation, coding guidelines and Coding Clinic for coding denials and/or adjustments.
- Extensive knowledge of Medicare Part A and how the regulatory requirements impact DRG assignments.
- Minimum of three years’ experience in clinical disciplines (RN, MD, FMG) or utilization review/case management in an acute care facility, with clinical knowledge.
- Strong background on pathophysiology and disease process.
Nice To Haves
- A Certified Coding Specialist (CCS), Certified Coding Associate (CCA) or Certified Documentation Improvement Practitioner (CDIP) certification status preferred.
- Certified Clinical Documentation Specialist (CCDS) credential preferred.
Responsibilities
- Assist and develop tracking mechanisms to demonstrate program impact.
- Assist in the development plans for both formal and informal education for physicians, nursing, and other clinical staff.
- Meets established productivity targets for record review and appropriate query placement.
- Demonstrates working knowledge of ICD-10 CM and ICD-10-PCS coding conventions and guidelines and applies to ongoing evaluation of medical record documentation.
- Designs and implements in collaboration with physician leadership specific tools to support medical record physician documentation.
- Facilitates multidisciplinary team in efforts for clinical documentation improvement.
- Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation.
- Improve overall quality and completeness of clinical documentation in the medical record in accordance with all regulatory requirements.
- Reviews inpatient Medical Record for identified payor populations on admission and throughout hospitalization.
- Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.
- Works collaboratively with coding staff to assure documentation of discharge diagnoses and any coexisting/comorbidities area complete reflection of the patient’s clinical status and care.
- Other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
