Clinical Documentation Improvement Specialist - Clinical Document Improvement - Full Time Days [...]

University of Southern California; Arcadia (CA); On-site; USD 64,000 - 84,000; Full time

Job summary

University of Southern California Arcadia Hospital seeks a CDI Specialist to review medical records and improve the accuracy and completeness of clinical documentation. The role involves collaboration with physicians, HIM professionals and nursing staff, with emphasis on ICD-10/ CPT guidelines and HIPAA compliance.

Candidates should have strong coding knowledge and the ability to initiate documentation queries.

Qualifications

• Minimum three years’ experience in clinical disciplines or utilization review in an acute care facility.
• Strong knowledge of ICD-10-CM/ICD-10-PCS coding conventions and guidelines.
• Initiate clinical documentation queries to obtain complete documentation.

Responsibilities

• Review medical records to improve the specificity of physicians' clinical documentation.
• Collaborate with physicians, HIM staff, and nursing to improve documentation and coding.
• Maintain confidentiality and HIPAA compliance; inform HIM leadership of workflow status.

Skills

ICD-10 knowledge

Coding guidelines

Query initiation

Communication skills

HIPAA compliance

Education

Nursing BSN or RHIT/RHIA

Anatomy/Physiology coursework

Tools

Windows

Coding software

Job description

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.

Preferred (Not 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.

Preferred (Not required)

Licenses and Certifications

Minimum (Required)

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

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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.