Clinical Documentation Specialist - Health Information Svcs

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

Job summary

Hawaii Pacific Health is seeking a Clinical Documentation Specialist to improve medical record documentation for CMS compliance and faster reimbursement. You will work with physicians, nursing, Case Management, and Health Information Management staff to obtain required documentation.

The role requires an RN license in Hawaii and at least five years of acute care clinical experience, including bedside nursing. CDI certification is preferred, with ongoing education on DRG-based coding practices.

Qualifications

• Bachelor’s Degree and/or equivalent combination of education, training, and/or experience.
• Current Hawai‘i RN license.
• Five (5) years of clinical experience in an acute care setting including patient bedside nursing.

Responsibilities

• Improve overall quality of medical record documentation to ensure CMS guidelines and expedite reimbursement.
• Obtain documentation through extensive interaction with physicians, nursing, Case Management and Health Information Management staff.
• Educate members of the patient care team on documentation guidelines.
• Ensure clinical information used in measuring and reporting outcomes is complete and accurate.

Skills

Organizational skills

Communication skills

Attention to detail

Education

Bachelor’s degree / equivalent

RN license (Hawaii)

Job description

Hawai'i Pacific Health is a not-for-profit health care network with over 70 locations statewide including medical centers, clinics, physicians and other caregivers serving Hawai'i and the Pacific Region with high quality, compassionate care. Its four medical centers - Kapi'olani, Pali Momi, Straub and Wilcox - specialize in innovative programs in women’s health, pediatric care, cardiovascular services, cancer care, bone and joint services and more. Hawai'i Pacific Health is recognized nationally for its excellence in patient care and the use of electronic health records to improve quality and patient safety.

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: Harbor Court

Work Schedule: Day - 8 Hours

Work Type: Full Time Regular

FTE: 1.000000

Bargaining Unit: Non-Bargaining

Exempt: Yes

Pay Range: 127,691 - 159,619 USD per year

Category: Health Information Management

Minimum Qualifications: Bachelor’s Degree and/or equivalent combination of education, training, and/or experience. Current Hawai‘i RN license. Five (5) years of clinical experience in an acute care setting that include patient 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.