Clinical Documentation Improvement Specialist - Clinical Document Improvement - Full Time Days (7:00AM to 3:30PM) (Non-Union, Non-Exempt)

Keck-Medicine-of-Usc; Arcadia (CA); Sur place; USD 96 000 - 126 000; Plein temps

Résumé du poste

The University of Southern California Arcadia Hospital seeks a CDI Specialist to review medical records and improve documentation accuracy and reflect illness severity. You will collaborate with physicians, HIM professionals and nursing staff while upholding HIPAA and building processes that boost coding quality.

You will participate in education on Medicare, ICD-10, CPT guidelines, and respond to coding denials with clinical justifications. USC is an equal opportunity employer.

Qualifications

• Graduate from a nursing program, RHIT/RHIA, or equivalent.
• Strong knowledge of ICD-10 CM/PCS coding conventions and guidelines.

Responsabilités

• Review medical records to improve documentation specificity.
• Educate physicians and staff on ICD-10-PCS and CPT guidelines.
• Participate in team meetings and improve workflows.
• Query physicians to clarify documentation and code accurately.
• Maintain HIPAA confidentiality and comply with regulations.

Connaissances

Critical thinking

Verbal communication

Written communication

Querying documentation

Team collaboration

Formation

Nursing degree / RHIT or RHIA

Health Information Management

Outils

Windows

EMR systems

Description du poste

ESSENTIAL JOB FUNCTIONS AND CORE RESPONSIBILITIESAssist 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 REQUIREMENTSEducationMinimum (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 ExperienceMinimum (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 CertificationsMinimum (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 TransparencyThe 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.POSITION SUMMARYThe 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.USC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability, or any other characteristic protected by law or USC policy. USC observes affirmative action obligations consistent with state and federal law. USC will consider for employment all qualified applicants with criminal records in a manner consistent with applicable laws and regulations, including the Los Angeles County Fair Chance Ordinance for employers and the Fair Chance Initiative for Hiring Ordinance, and with due consideration for patient and student safety. Please refer to the Background Screening Policy Appendix D for specific employment screen implications for the position for which you are applying.We provide reasonable accommodations to applicants and employees with disabilities. Applicants with questions about access or requiring a reasonable accommodation for any part of the application or hiring process should contact USC Human Resources by phone at [phone], or by email at [e-mail]. Inquiries will be treated as confidential to the extent permitted by law.Notice of Non-discriminationEmployment EquityRead USC’s Clery Act Annual Security ReportUSC is a smoke-free environmentDigital AccessibilityIf you are a current USC employee, please apply to this USC job posting in Workday by copying and pasting this link into your browser:https://wd5.myworkday.com/usc/d/inst/1$9925/9925$154663.htmld