Clinical Documentation Improvement Specialist - Health Information Management - Full Time 8 Hours Day (Union, Non-Exempt) Job at Keck Medicine of USC, Arcadia, CA

a1d0azVoam5Qd2R4NlpxNEEwK1I0cmNxenc9PQ==
  • Keck Medicine of USC
  • Arcadia, CA

Job Description

Position Summary

The CDI Specialist is responsible for reviewing medical records to facilitate the accurate representation of the severity of illness by improving the specificity of the physicians’ clinical documentation. This involves extensive record review, interaction with physicians, HIM professionals, and nursing staff. Involved with educational activities to maintain up-to-date information on Medicare, ICD-10, and CPT coding, and documentation guidelines. Active participation in team meetings by providing recommendations on query structure, process, and workflow. Responds to coding denials with clinical justifications and coding conventions. Maintain confidentiality of information acquired pertaining to patients, physicians, associates, and adheres to HIPAA regulations. Keep the CDI team and HIM Manager or Director informed of workflow status and potential backlog issues.

Essential Job Functions And Core Responsibilities

  • Assist and develop tracking mechanisms to demonstrate program impact.
  • Assist in the development plans for both formal and informal education for physicians, nursing, and other clinical staff.
  • Meets established productivity targets for record review and appropriate query placement.
  • Demonstrates working knowledge of ICD-10 CM and ICD-10-PCS coding conventions and guidelines and applies to ongoing evaluation of medical record documentation.
  • Designs and implements in collaboration with physician leadership specific tools to support medical record physician documentation.
  • Facilitates multidisciplinary team in efforts for clinical documentation improvement.
  • Identifies 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.
  • Reviews inpatient Medical Record for identified payor populations on admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.
  • Works collaboratively with coding staff to assure documentation of discharge diagnoses and any coexisting/comorbidities area complete reflection of the patient’s clinical status and care.
  • Other duties as assigned.

Job Requirements Education Minimum (Required)

  • Graduate from a program of nursing, BSN, Health Information Management RHIT, RHIA, or foreign medical doctorate degree strongly preferred.
  • Accredited college course work in human anatomy and/or physiology, medical terminology, and disease process is required. Work Experience Minimum (Required)
  • Competent with Windows based software programs.
  • Extensive knowledge of ICD-10 CM and ICD-10-PCS coding, sequencing, and documentation guidelines skills and working knowledge of the AHA Coding Clinic preferred with experience in CPT/HCPCS for hospital and/or clinic records.
  • 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.
  • Strong background on pathophysiology and disease process. Licenses and Certifications Preferred (Not required)
  • 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

Job Tags

Hourly pay, Full time, Work experience placement, Local area,

Similar Jobs

Blue Sky Pest Control

Pest Control Service Technician and Termite Technician Job at Blue Sky Pest Control

 ...Blue Sky Pest Control is hiring full-time Pest Control Technicians (Exterminators) ; $47,000 - $57,000 (DOE; includes hourly pay) . No Experience needed; w e provide paid training (including state licensing). Offices located in Phoenix and Gilbert, Arizona. Benefits... 

ABC and LOL Child Care Center and Preschool

Substitute Teacher Job at ABC and LOL Child Care Center and Preschool

 ...while inspiring our children to reach their goals in life. If you have at least two year of experience in this field, college-level education and are enthusiastic, with a positive outgoing attitude then we would love to meet you. Duties clear communication with... 

Foxconn Assembly LLC

Warehouse & Shipping Manager Job at Foxconn Assembly LLC

 ...Job Overview We are seeking a highly organized and results-driven Warehouse & Shipping Manager to oversee all activities related to Warehouse (WH), Shipping (SD). This role is responsible for managing warehouse operations and contents by establishing and overseeing... 

Rare Earth Adventures

Adventure Guide Job at Rare Earth Adventures

 ...an overnight extended day trip, making sure our guests are comfortable, having fun, and present in the experience is key. We are an outdoor education-focused company, so these trips are to be as instructional and informative as possible. These are the trips we are... 

Gpac

Diesel Mechanic/ Trailer Technician Job at Gpac

Gpac is currently partnering with a truck dealer who both works on and sells semi-trucks...  ...work ranging from alignments, to body work, mechanic work, frame work, etc. Right now, they...  ...of an experienced T railer Technician . Trailer Technician Responsibilities: Performs...