Clinical Documentation Specialist - Health Information Servi

Hawaii Pacific Health; Lihue (HI); On-site; USD 128,000 - 160,000; Full time

Job summary

Wilcox Medical Center, part of Hawai‘i Pacific Health, seeks a Clinical Documentation Specialist to enhance medical record accuracy and CMS compliance. The role works with physicians, nurses, Case Management, and HIM to secure complete documentation for appropriate DRG-based reimbursements.

Ideal candidates have a Hawai‘i RN license, a Bachelor’s degree or equivalent, and at least five years of acute care experience. CDI certification and coding experience are preferred. EOE/AA/Disabled/Vets.

Qualifications

• Current Hawai‘i Registered Nurse License.
• Bachelor’s degree and/or equivalent combination of education, training and experience.
• Five (5) years of clinical experience in an acute care setting that include inpatient bedside nursing.

Responsibilities

• Improve the quality of medical record documentation to ensure CMS guidelines and reimbursements.
• Obtain documentation through interaction with physicians, nursing, Case Management and Health Information Management staff.
• Educate patient care team on documentation guidelines.

Skills

Organizational skills

Attention to detail

Communication skills

Education

Hawai‘i Registered Nurse License

Bachelor's degree in Nursing or equivalent

Tools

CDI knowledge

InterQual/Milliman criteria

DRG coding experience

Job description

Founded in 1938, Wilcox Medical Center is a not-for-profit medical center dedicated to providing the Kaua‘i community with accessible quality health care. The largest medical center on Kaua‘i, it is a state-of-the‑art acute care facility with a full suite of services offering 30 specialties and programs, including cardiology, emergency, family practice, gastroenterology, health management, internal medicine, neurology, OB-GYN, oncology, orthopedics, pediatrics and urology. Its 18-bed emergency department serves as the island’s Primary Stroke Center. The medical center also has four birthing suites, seven intensive care beds and 20 same‑day surgery beds. Wilcox is the first American College of Surgeons‑verified Level III Trauma Center in the state of Hawai‘i. Wilcox is part of Hawai‘i Pacific Health, one of the state’s leading health care systems and a not-for-profit health care organization with medical centers, clinics, physicians and other caregivers working together to create a healthier Hawai‘i.

Health Information Services (HIS) processes patient medical records and releases health information to patients, physicians, and other outside facilities for treatment, payment, or review. HIS is the custodian and gatekeeper for privacy of the organization’s medical records and also generates the coding procedures for data collection, research, and reimbursement. With the widespread computerization of health records and other information sources, including hospital administration functions and health human resources information, health informatics and health information technology are being increasingly used in the health care sector.

If you are highly organized and detail-oriented, you can help to manage our clinical records according to the highest ethical standards of patient privacy and security. As the Clinical Documentation Specialist, you will work to improve the overall quality of medical record documentation to ensure compliance with Medicare and Medicaid (CMS) guidelines and to expedite reimbursement. You will use both clinical and coding knowledge to obtain documentation through extensive interaction with physicians, nursing, other patient caregivers, Case Management and Health Information Management staff. You will also ensure that the clinical information used in measuring and reporting outcomes is complete, accurate, and that reimbursement is received for services rendered to patients with DRG‑based payers. You will also educate members of the patient care team on documentation guidelines. We are looking for someone with exceptional organizational and communication skills, attention to detail and protocol and a commitment to delivering the highest quality health care to Hawai‘i’s people.

Location:

Wilcox Medical Center

Work Schedule:

Day - 8 Hours

Work Type:

Full Time Regular

FTE:

1.000000

Bargaining Unit:

Non-Bargaining

Exempt:

Yes

Req ID

34690

Pay Range:

127,691 - 159,619 USD per year

Category:

Health Information Management

Minimum qualifications:

Current Hawai‘i Registered Nurse License. Bachelor’s degree and/or equivalent combination of education, training and experience. Five (5) years of clinical experience in an acute care setting that include inpatient bedside nursing.

Preferred Qualifications:

Clinical Documentation Improvement (CDI) certification. Experience with InterQual, Milliman or other nationally recognized Utilization Management criteria. Experience with DRGs or inpatient ICD-10-CM/PCS coding.

EOE/AA/Disabled/Vets

Hawai‘i Pacific Health offers a comprehensive and competitive total rewards package that includes pay and benefits. Rate of pay for selected candidates will be determined by various factors including knowledge, skills, abilities, relevant experience and training, as well as internal peer equity.