Clinical Documentation Improvement Specialist - Clinical Document Improvement - Full Time 8 Hours Days (7:00AM to 5:30PM) (Non-Union, Non-Exempt)

Essential Job Functions and Core Responsibilities

• Assist and develop tracking mechanisms to demonstrate program impact.
• Absorb and develop plans for both formal and informal education for physicians, nursing, and other clinical staff.
• Maintain and meet established productivity targets for record review and appropriate query placement.
• Show working knowledge of ICD-10 CM and ICD-10-PCS coding conventions and guidelines and apply to ongoing evaluation of medical record documentation.
• Design and implement, in collaboration with physician leadership, specific tools to support medical record physician documentation.
• Facilitate multidisciplinary teams in efforts for clinical documentation improvement.
• Identify 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.
• Review inpatient Medical Record for identified payor populations on admission and throughout hospitalization. Analyze clinical status of patient, current treatment plan and past medical history and identify potential gaps in physician documentation.
• Collaborate with coding staff to ensure documentation of discharge diagnoses and any coexisting/comorbidities accurately reflects the patient’s clinical status and care.
• Other duties as assigned.

Job Requirements

• Education: Graduate from a program of nursing, BSN, Health Information Management RHIT, RHIA, or foreign medical doctorate degree (preferred).
• Experience: Competent with Windows based software programs. Extensive knowledge of ICD-10 CM and ICD-10-PCS coding, sequencing, and documentation guidelines (preferred). 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 (required).
• Licenses and Certifications: 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).

Pay Transparency

The hourly rate range for this position is $46.27 - $60.73. When extending an offer of employment, the University of Southern California Arcadia Hospital considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, State, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.