Clinical Documentation Specialist - Health Information Svcs

Hawaii Pacific Health; Honolulu (HI); On-site; USD 133,000 - 166,000; Full time

Job summary

Hawaii Pacific Health’s Straub Benioff Medical Center in Honolulu seeks a Clinical Documentation Specialist to improve medical record quality, ensure CMS compliance, and speed reimbursement through thorough chart review and coding knowledge.

The role requires Hawaii RN license, a bachelor’s degree or equivalent, and at least five years of acute care nursing; CDI certification and DRG/ ICD-10 experience are preferred.

Qualifications

• Current Hawai‘i registered nurse license.
• Bachelor’s degree or equivalent education/experience.
• Five years of acute care nursing experience.

Responsibilities

• Improve medical record documentation quality to CMS guidelines.
• Obtain documentation via physicians, nursing, and care teams.
• Educate care teams on documentation guidelines and DRG accuracy.
• Ensure data used to measure outcomes is complete and reimbursement is secured.

Skills

Attention to detail

Organizational skills

Communication

Education

Bachelor's degree or equivalent

Job description

Founded in 1921, Straub Benioff Medical Center includes a 159-bed hospital in Honolulu, a network of neighborhood clinics and a visiting specialist program that reaches throughout the state of Hawai'i. With over 200 physicians who are leaders in their fields, Straub provides its patients with diagnoses and treatments for more than 32 different medical specialties, including bone and joint, heart, cancer, endocrinology/diabetes, family medicine, gastroenterology, geriatric medicine, internal medicine, vascular and urology. Straub is home to the Pacific Region’s only multidisciplinary burn treatment center. The hospital consistently brings new technologies and innovative medical practices to Hawai'i, such as minimally invasive cardiac surgery and total joint replacement.

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: Straub Benioff Medical Center

Work Schedule: Day - 8 Hours

Work Type: Full Time Regular

FTE: 1.000000

Bargaining Unit: Non-Bargaining

Exempt: Yes

Req ID 34889

Pay Range: 132,804 - 166,005 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 acute care nursing experience.

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.