Clinical Documentation Integrity Specialist (Hybrid-Portland)

Adventist Health • Portland, OR

330d

About The Position

In a bustling cosmopolitan area surrounded by nature, Adventist Health Portland has been one of the area's leading healthcare providers since the 1800s. In partnership with OHSU, we are comprised of a 302-bed hospital, 11 medical offices, home care services, comprehensive cancer care and a vast scope of award-winning services located throughout East Portland and the surrounding areas. There are many outdoor adventures readily available, including carving the snow at North America's only year-round ski resort, hiking along the Columbia River Gorge or taking a day trip to the unmatched beauty of the Oregon coast. Job Summary: Reviews, evaluates and assesses medical records of patients, looks for specificity of an illness, the accuracy of the clinician's documentation, coding requirements and documentation of important medical details to ensure the overall quality and completeness of clinical documentation of the patient medical record and ensure it is in compliance with government and other regulations. Works on problems of moderate to diverse scope requiring some interpretation of policies and guidelines. Applies working knowledge of the techniques, principles, theories and concepts to complete routine and non-routine assignments. Runs program(s) with moderate budget/impact.

Requirements

• Associate's/Technical Degree or equivalent combination of education/related experience: Required
• Bachelor's Degree: Preferred
• Three years' clinical experience: Required
• Two years' clinical documentation experience: Required
• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): Required
• Current licensed RN, medical provider or equivalent: Required
• Foreign Medical Doctor (FMD) or Medical license MD (MD) or Registered Nurse (RN): Required

Responsibilities

• Evaluates and assesses medical records of patients for specificity of illness and accuracy of clinician's documentation.
• Ensures compliance with coding requirements and documentation of important medical details.
• Performs coding, working DRG assignment and enters all review activity into tracking software.
• Analyzes and interprets medical records and clinical documentation, formulates appropriate physician queries.
• Performs follow up on incomplete physician queries to obtain answers while the patient is still in house.
• Updates 'working DRG' as documentation supports changes in DRG assignment.
• Reviews quality of medical records and communicates conflicting data to department lead.
• Keeps abreast of regulatory changes related to documentation and coding.
• Acts as a liaison between medical staff and coding department.
• Collaborates with physicians and coding staff to ensure accurate clinical information in medical records.
• Attends scheduled physician and care management meetings as requested.
• Performs other job-related duties as assigned.

Benefits

• Adventist Health is committed to the safety and wellbeing of our associates and patients.
• Required vaccinations including measles, mumps, flu, COVID-19 vaccine, etc.

What This Job Offers

• Industry: Ambulatory Health Care Services
• Education Level: Associate degree