Clinical Documentation & Coding Specialist

Memorialhospitalgardena; Gardena, Northern (CA, KY); Hybrid; USD 86,000 - 144,000; Full time

Job summary

Memorial Hospital of Gardena is seeking a Clinical Documentation Specialist to ensure accuracy and completeness of patient records. You will review clinical documentation, identify missing or inaccurate data, and assign ICD-10-CM/CPT codes to diagnoses and procedures while ensuring HIPAA and Joint Commission compliance.

This role involves educating providers on documentation best practices, participating in CDI initiatives, and maintaining up-to-date knowledge of terminology and regulatory

Qualifications

• Minimum of two (2) years of experience in clinical documentation or coding.
• Strong understanding of medical terminology and coding guidelines.
• Proficient in Microsoft Office Suite and electronic health record (EHR) systems.
• Critical thinking, service excellence and good interpersonal communication skills, ability to read/comprehend written instructions, strong organizational skills, ability to follow verbal instructions, and PC (computer) skills.
• A capacity to learn, synthesize, make critical judgments, work independently, place patients and families first, and collaborate with the team members who are recognized leaders within healthcare.

Responsibilities

• Review and analyze physician documentation, including progress notes, discharge summaries, and operative reports.
• Identify and query missing or inaccurate information with physicians and other healthcare providers.
• Assign appropriate ICD-10-CM and CPT codes to diagnoses and procedures.
• Ensure documentation complies with regulatory requirements, including HIPAA and The Joint Commission standards.
• Participate in clinical documentation improvement (CDI) initiatives.
• Educate and train healthcare providers on documentation best practices.
• Stay up to date on changes to medical terminology, coding guidelines, and regulatory requirements.
• Uses clear, concise, professional communication with coworkers, patients, all customers internal and external.
• Uses AIDET in interactions with patients and family members.
• Acts with a sense of urgency when performing tasks.
• Basic unit/department maintenance such as keeping files, drawers, cabinets free from unnecessary clutter.
• Reports on any equipment and or environmental issues for repair.
• Abides by HIPAA regulations.
• Speaks up to stop the line and escalates potential safety events if necessary.
• Completes and attends monthly training assigned.
• Other duties as assigned.

Skills

Medical terminology

Coding guidelines

Interpersonal communication

Critical thinking

Patient focus

Education

Bachelor's degree

CCS Certification

Tools

Microsoft Office

Electronic Health Records (EHR)

Job description

Memorial Hospital of Gardena is seeking a Clinical Documentation Specialist to ensure accuracy and completeness of patient records. You will review clinical documentation, identify missing or inaccurate data, and assign ICD-10-CM/CPT codes to diagnoses and procedures while ensuring HIPAA and Joint Commission compliance.

This role involves educating providers on documentation best practices, participating in CDI initiatives, and maintaining up-to-date knowledge of terminology and regulatory