Clinical Documentation Specialist

3 weeks ago

Pasadena CA, United States CEDARS-SINAI Full time

Job Description Align yourself with an organization that has a reputation for excellence. Cedars-Sinai was awarded the National Research Corporation’s Consumer Choice Award 19 years in a row for providing the highest-quality medical care in Los Angeles. We were also awarded the Advisory Board Company’s Workplace of the Year. Cedars-Sinai offers an outstanding benefits' package that includes health care, paid time off and a 403(B). Join us Discover why U.S. News & World Report has named us one of America’s Best Hospitals. What Will I be doing in this role? The Clinical Documentation Specialist performs record review (quantitative and qualitative) and assesses the level of compliance with stated regulatory requirements by area of job focus. Assigns a working MS-DRG/APR-DRG. Assists in clarifying clinical information used for measuring and reporting physician and medical center outcomes which incorporates current DRG methodologies (e.g. MS-DRGs, etc.) by CMS and/or other regulatory/quality reporting bodies (e.g. APR-DRGs, SOI, ROM, etc). Issues queries to members of the patient care team – primarily physicians – regarding possible diagnoses or to improve the specificity of diagnoses thru enhanced clinical documentation. Facilitates modifications to clinical documentation as needed to support component stated previously. Leads or provides education/training to clinical care (physicians, nurses, etc.) and administrative support team members regarding the clinical documentation requirements essential for demonstrating quality patient care (SOI, ROM, etc.), the regulatory interpretation of outcomes for focused diagnoses, and their impact on reimbursement and quality reporting for the organization. Assists in developing educational materials as needed. Demonstrates knowledge of applicable regulatory standards/requirements by applying them accurately when providing guidance to customers. Accurately applies knowledge during record review activities. Supports ad-hoc reviews or data collection activities for focused or special research studies conducted within the organization. Qualifications Requirements: High School Diploma or GED required. Bachelor's degree in Nursing, Health Information Management or a similar major preferred. A foreign Medical Degree may be considered. RN State License - Current RN license (not limited to State of California) or higher clinical degree (i.e., MD), or Registered Health Info Admin, or Registered Health Info Tech required upon hire. Clinical Documentation Improvement Professional (CDIP) or Certified clinical Documentation Specialist (CCS) preferred. A minimum of 3 years of acute care experience required. A minimum of 3 years of experience in Utilization Review, Coding, or Case Management experience preferred. Req ID : 2694 Working Title : Clinical Documentation Specialist - 8 Hour Days Department : CSRC CDI Services Business Entity : Cedars-Sinai Medical Center Job Category : Patient Financial Services Job Specialty : Revenue Integrity Overtime Status : NONEXEMPT Primary Shift : Day Shift Duration : 8 hour Base Pay : $49.04 - $78.46

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