Clinical Documentation Integrity Specialist

Adventist Health • Glendale, CA

81d

About The Position

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect. Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work. The position involves reviewing, evaluating, and assessing medical records of patients, ensuring the accuracy of clinician documentation, coding requirements, and compliance with regulations.

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 documentation.
• Performs coding, working DRG assignment, and enters all review activity into tracking software.
• Analyzes and interprets medical records and 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.
• Communicates conflicting data found in medical records to the department lead.
• Keeps abreast of regulatory changes related to documentation and coding.
• Acts as a liaison between medical staff and the coding department.
• Collaborates with physicians and coding staff to ensure accurate clinical information.
• Attends scheduled physician and care management meetings as requested.

What This Job Offers

• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees