Clinical Documentation Integrity Specialist II - Hybrid FT Days

Torrance-Memorial-Medical-Center; Torrance (CA); On-site; USD 73,000 - 121,000; Full time

Job summary

Torrance Memorial Medical Center is seeking a Clinical Documentation Integrity Program Specialist II to enhance accuracy and completeness of inpatient health records through expert review of physician documentation, labs, and related data within 24-48 hours of admission.

The role emphasizes collaboration with medical staff, ongoing education for clinicians, and program development to meet regulatory standards and improve patient outcomes.

Qualifications

• Minimum of three years in medical/surgical acute care nursing or medical degree with CDI coding experience.
• CCDS or CDIP certification preferred.

Responsibilities

• Assess patients' conditions against physician documentation per standards.
• Obtain additional documentation when information is conflicting or incomplete.
• Collaborate with physicians and staff to improve documentation quality.

Skills

Data analysis

Documentation integrity

Adult education

Interprofessional collaboration

Project coordination

Education

Bachelor's degree in healthcare

Advanced degree option

Tools

Documentation software

Job description

The Clinical Documentation Integrity Program Specialist II facilitates accurate, complete and consistent clinical documentation within the inpatient health record to support reporting of high-quality healthcare data and coding.

Core Competencies

• Assesses patients' clinical conditions and risks compared to the physicians' documentation in accordance with regulatory and documentation standards using applicable coding conventions, rules and guidelines. Through data analysis, determines patient populations upon which to focus that will yield the greatest impact for improvement in outcomes.
• Demonstrates knowledge of clinical conditions and procedures as it relates to documentation integrity requirements to support the appropriate internal and external reporting of a) principal diagnosis, pertinent secondary diagnoses and procedures for accurate severity of illness, expected risk of mortality and complexity of care of the inpatient.
• Obtains additional documentation from physician or other qualified healthcare provider for clarification when there is conflicting, incomplete or ambiguous information in the healthcare record regarding any reportable data elements dependent on health record documentation.
• Uses clinical/nursing/coding knowledge to concurrently review and assess the medical record within 24-48 hours of admission including but not limited to physician documentation, lab and radiology results, nursing, nutrition, physical therapy and other provider's documentation to determine that the most accurate severity of illness and expected risk of morality is reflected in the patient's health record.
• Utilizes computer software for documentation of reviews and clarifications. Manages the development of or utilizes computerized tracking methods to identify and prioritize records for review each day.
• Elevates outcomes through solicited feedback to encourage continuous improvement.
• Recognizes physicians and other clinicians who demonstrate compliance with documentation requirements.
• Understands and applies educational techniques for adult learners.
• Works collaboratively with Medical Staff leaders in addressing issues of physicians who require further education to help them with documentation requirements.
• Assists in developing, implementing, and managing an effective and efficient CDI program. Works collaboratively with and educates physicians and other providers regarding clinical documentation integrity and the need for accurate and complete documentation in the health record.
• Participates in the ongoing evaluation of the structure, processes and outcomes of the data collection and benchmarking systems. Works with HIM management and the coding team in developing and maintaining current materials to prompt clinicians to accurately document (example: query forms). Actively manages the ongoing evaluation of the CDI program and provides creative, constructive, and realistic recommendations for change.
• Partners with coding professionals to ensure accuracy and completeness of diagnostic and procedural data based on supporting documentation to determine severity of illness/risk of mortality and final MS-DRG.
• Reviews clinical issues with coding professionals in health record to help clarify and support codable and reported data.
• Participates in the ongoing evaluation and development of the Clinical Documentation Improvement Plan and provides creative, constructive and realistic recommendation for change.
• Assists in developing an annual strategic educational plan based upon changes in regulatory standards and physicians' and other clinicians' level of compliance.
• Maintains productivity and quality standards as outlined in policy and procedure.

Department Specific Competencies

• Works on many different projects during one time frame and coordinates work so deadlines are met.
• Responds to changing priorities.
• Advances professional knowledge and practice through continuing education.
• Demonstrates strong organizational skills and attention to detail.
• Actively participates in the continuous improvement model.

Education

• Degree: Bachelors
• Program: Healthcare
• Additional Information: Advanced degree can be in Nursing, Medicine, HIM/Coding or other related disciplines.

Experience

• Number of Years Experience: 3 Type of Experience: CDI Specialist
• Number of Years Experience: 3 Type of Experience: See below.
• Additional Information: Minimum of three years well-rounded medical/surgical acute care nursing or Medical Degree with two to three years demonstrating functioning as a physician or Certification Clinical Coder demonstrating a minimum of three years acute in-patient coding.

License / Certification Requirements

Cert. Clinical Documentation Specialist(CCDS) or Cert. Documentation Improvement Practitioner(CDIP)

Compensation Range

$52.89 - $88.38 / Hour