Clinical Documentation Specialist II - 8 Hour Days - Los Angeles, CA

This position is available to Veterans, Transitioning Military, National Guard and Reserve Members, Military Spouses, Wounded Warriors, and their Caregivers.

About the Role

The Clinical Documentation Specialist (CDS) II is a more experienced CDS, spending at least 75% of their time on independent reviews without supervision, creating queries, and facilitating their follow-up. Level 2 specialists create trend reports to provide insights into documentation practices and engage directly with physicians to manage queries. They spend 25% of their time mentoring the CDS I and providing feedback to leadership.

Responsibilities

• Reviews and analyzes clinical information with the electronic health record to identify areas within the chart for potential gaps in physician/provider documentation.
• Formulates credible clinical documentation clarifications to improve clinical documentation of principal diagnosis, co-morbidities, present on admission (POA), quality core measures, and patient safety indicators (PSI).
• Confirms and/or assigns a working diagnostic related group (DRG) and severity level using coding rules and guidelines with follow-up reviews as required by length of stay (LOS) standards.
• Extracts essential data elements for reporting and tracking, specifically for Joint Commission record reviews, CORE measures, severity of illness (SOI)/risk of mortality (ROM) assessments, patient safety indicators (PSI), and revenue optimization criteria, dedicating full attention to core measure responsibilities.
• Engages in ongoing queries with physicians and providers to clarify and enhance documentation specificity in medical records.
• Conducts post-discharge reviews for comparative analysis of clinical documentation integrity (CDI) and Coding assigned codes.
• Communicates with physicians, nurse practitioners, case managers, coders, and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment, decision-making, and medical documentation.
• Identifies trends related to documentation issues, provider-specific concerns, code-specific needs, etc.
• Makes presentations to peer audiences on various topics, such as clinical diagnoses, regulatory changes, guidelines, new practices, etc.
• Mentors and precepts Clinical Documentation Specialist Level 1.
• Initiates special clinical documentation integrity (CDI) projects for process improvement.

Requirements

• High School Diploma/GED (minimum)
• Associate Degree/College Diploma (minimum)
• Clinical Degree – Nursing, Health Information, or Foreign Trained Medical graduate (preferred)
• 2 years performing CDI reviews within an acute care facility or bedside experience (minimum)
• 3 years utilization review, coding, or case management experience (preferred)

Qualifications

• RN State License (upon hire, minimum)
• Certified Clinical Documentation Specialist (CCDS)
• Registered Health Information Administrator (RHIA)
• Clinical Documentation Integrity Practitioner (CDIP)

Pay

$52.55 – $84.08 per hour