Clinical Documentation Integrity Specialist (HYBRID, White Memorial)

Adventist Health; Los Angeles (CA); On-site; USD 85,000 - 110,000; Full time

Job summary

Adventist Health seeks a Clinical Documentation Specialist to review patient records for illness specificity, accuracy of clinician documentation, and coding requirements. You will ensure complete and compliant documentation of medical records and support DRG assignments.

This role works with physicians and coding staff to maintain data integrity, communicates findings, and adapts to regulatory changes through ongoing education and collaboration.

Qualifications

• Associates/Technical degree or equivalent; three years of clinical experience; two years in clinical documentation is required.
• CCDS or DIP certification is required; current licensed RN, medical provider, or equivalent is required.

Responsibilities

• Evaluates and assesses medical records for specificity and documentation accuracy; conducts coding and DRG assignment; records review activity.
• Formulates physician queries, follows up on incomplete queries, and updates DRG as supported by documentation.
• Reviews data integrity, communicates deficiencies to department leads, and ensures compliance with federal/state regulations.
• Keeps abreast of regulatory changes in documentation and coding; participates in ongoing education sessions.
• Acts as liaison between medical staff and coding department to ensure accurate clinical information.

Skills

Clinical documentation

Medical records analysis

DRG assignment

Physician queries

Education

Associate/Technical Degree

Bachelor's Degree

Tools

Tracking software

Job description

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.

Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.

Job Summary

Reviews, evaluates and assesses medical records of patients, looks for specificity of an illness, the accuracy of the clinician’s documentation, coding requirements and documentation of important medical details to ensure the overall quality and completeness of clinical documentation of the patient medical record and ensure it is in compliance with government and other regulations. Works on problems of moderate to diverse scope requiring some interpretation of policies and guidelines. Applies working knowledge of the techniques, principles, theories and concepts to complete routine and non-routine assignments. Runs program(s) with moderate budget/impact.

Job Requirements

Education and Work Experience

• Associate's/Technical Degree or equivalent combination of education/related experience: Required
• Bachelor's Degree: Preferred
• Three years' clinical experience: Required
• Two years' clinical documentation experience: Required

Licenses/Certifications

• Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): Required
• Current licensed RN, medical provider or equivalent: Required

Essential Functions

• Evaluates and assesses medical records of patients, looks for specificity of an illness, the accuracy of the clinician’s documentation, coding requirements and documentation of important medical details to ensure the overall quality and completeness of clinical documentation of the patient medical record. Performs coding, working DRG assignment and enters all review activity into tracking software.
• Analyzes and interprets medical records and clinical documentation and formulates appropriate physician queries. Performs follow up on incomplete physician queries to obtain an answer while the patient is still in house. Updates “working DRG” as documentation supports, or physician query answer supports a change in the DRG assignment.
• Reviews quality of medical record and communicates when conflicting data are found, the clinical documentation integrity specialist (CDIS) conveys deficiencies to the department lead for more information to resolve the conflict.
• Keeps abreast of regulatory changes related to documentation, coding and communicate these changes to appropriate staff. Follows documentation guidelines and legal requirements to ensure compliance with federal and state regulatory bodies. Attends ongoing education sessions.
• Acts as a liaison between the medical staff and the coding department. Works collaboratively with physicians and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate clinical diagnosis and level of severity is captured for the level of service rendered to all patients. Attends scheduled physician and care management meetings as requested and reviews requested cases prior to the meetings.
• Performs other job-related duties as assigned.

Organizational Requirements

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.

Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.