Clinical Documentation Specialist - Clinical Doc Integrity - Full Time 8 Hour Days (Non-Exempt) (Non-Union)

University of Southern California • Alhambra, CA

8d • Onsite

About The Position

The Clinical Documentation Specialist (CDS) provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation of acute care services. Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Improves the overall quality and completeness of clinical documentation by working closely with providers and the application of coding guidelines, evidence-based knowledge, analysis, in-depth review, interpretation, identification of opportunities, communication, and consistent follow-up and evaluation of concurrent and retrospective (as required) medical record documentation.

Requirements

• High school or equivalent
• Specialized/technical training
• Graduate of an accredited school of registered nursing and/or foreign medical graduate.
• 2 years Clinical documentation improvement experience.
• 3 years Clinical experience in an acute care setting.
• Demonstrates knowledge of ICD10-CM & PCS with respective coding guidelines & regulations for coding and reporting.
• Proficient on Inpatient Prospective Payment System (IPPS) documentation requirements for proper APR and MS DRGs assignment.
• Care delivery documentation systems and related medical record documentation.
• Strong broad based clinical knowledge and understanding of pathology/physiology of disease processes.
• Excellent written and verbal communication skills.
• Excellent critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurses, and hospital staff.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time oriented environment.

Nice To Haves

• Working knowledge of Medicare reimbursement system and coding structures.

Responsibilities

• Identifies his/her respective service line(s) admissions in the CDI software/tool; and prioritizes reviews by age and payer.
• Completes his/her assignments by the end of the day
• Conducts new inpatient admissions reviews and proper working DRG assignment within 2 working days.
• Conducts follow up reviews and respective working DRG updates at least every 2 working days.
• Achieves a physician response rate of 100% through CDI education and interaction with physicians, identifying non-responders and intervening as necessary.
• Follows the query escalation process when no response.
• Identifies opportunities to improve documentation through physician query generation.
• Practice the mnemonic ‘MEAT’ (Monitored, Evaluated, Assessed or Treated) for building compliant and non-leading CDI queries.
• Applies evidence-based clinical criteria for clinical validation of diagnoses
• Utilizes the CDI software properly for tracking of CDI metrics and to assure compliance: documentation of pertinent clinical findings, compliant/non-leading queries, completion of all the required fields for data integrity and professional communication with coders and other staff members
• Directs a proper and complete CDI-Coding reconciliation process to accurate capture the complexity of the patients.
• Performs retrospective reviews and queries when necessary.
• Performs other related duties as assigned.

Benefits

• Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)
• Registered Nurse - RN (CA Board of Registered Nursing) OR Foreign Medical Graduate. (or valid state of residence Registered Nurse license for out-of-state employees [working remotely])
• Certification - Job Relevant Certified Clinical Documentation Specialist (CCDS); OR Certified Documentation Improvement Practitioner (CDIP)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED