Clinical Documentation Specialist
Found in: beBee jobs US - 1 week ago
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.
QualificationsRequirements:
- 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.
About UsCedars-Sinai is a leader in providing high-quality healthcare encompassing primary care, specialized medicine and research. Since 1902, Cedars-Sinai has evolved to meet the needs of one of the most diverse regions in the nation, setting standards in quality and innovative patient care, research, teaching and community service. Today, Cedars- Sinai is known for its national leadership in transforming healthcare for the benefit of patients. Cedars-Sinai impacts the future of healthcare by developing new approaches to treatment and educating tomorrow's health professionals. Additionally, Cedars-Sinai demonstrates a commitment to the community through programs that improve the health of its most vulnerable residents.
About the TeamCedars-Sinai is one of the largest nonprofit academic medical centers in the U.S., with 886 licensed beds, 2,100 physicians, 2,800 nurses and thousands of other healthcare professionals and staff. Choose this if you want to work in a fast-paced environment that offers the highest level of care to people in the Los Angeles that need our care the most.
Req ID : HRC1444262
Working Title : Clinical Documentation Specialist
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 : $ $78.46
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