Clinical Documentation Improvement Specialist

4 weeks ago

San Diego, United States Paradigm Professional Health Services Full time

**Company Overview**:
Paradigm Professional Health Services, Inc. (Paradigm) is a government contractor specialized in providing qualified, reliable, and culturally competent health and education professionals to meet the mission objectives of Federal agencies nationwide.

**Position Overview**:
Paradigm currently has an opening for a **full-time (40 hours/week)** Clinical Documentation Specialist (CDS) or Clinical Documentation Improvement Specialist (CDIS) to provide** ON-SITE** auditing services for the Veterans Administration (VA) San Diego Healthcare System. The CDS/CDIS will be responsible for abstracting medical record data and assigning codes using current clinical classification systems for the type of care provided.

**Period of Performance**:
Base Year #: 07/01/2024 - 06/30/2025

Option Year #1: 07/01/2025 - 06/30/2026

Option Year #2: 07/01/2026 - 06/30/2027

Option Year #3: 07/01/2027 - 06/30/2028

Option Year #4: 07/01/2028 - 06/30/2029

**Places of Performance**:
VA San Diego Healthcare System

3350 La Jolla Village Dr.

San Diego, CA 92161

**Hours of Work**:
Monday - Friday; 7:30 AM to 4:00 PM

**Required Qualifications**:

- Able to start work immediately after background security check is cleared;
- CDIS, CCDS, or CPC certification** (preferred)**;
- Knowledge of coding and documentation concepts, guidelines, and clinical terminology;
- Ability to interpret and analyze all information in a patient’s health record, including laboratory and other test results, to identify opportunities for more precise and/or complete documentation in the heath record;
- Knowledge of anatomy and physiology, pathophysiology, and pharmacology;
- Ability to establish and maintain strong verbal and written communication with providers;
- Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines;
- Knowledge of coding rules and requirements to include clinical classification systems (such as current versions of ICD and CPT), complication or co morbidity/major complication or co-morbidity (CC/MCC), Medicare Severity Diagnosis Related group (MS-DRG) structure, and Present on Admission (POA) indicators;
- Knowledge of severity of illness and risk of mortality indicators; and
- Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues.

**Essential Duties and Responsibilities**:

- Knowledge and experience of coding using ICD 9 and ICD 9.
- Develop and/or update healthcare system policy memorandum pertaining to documentation improvement.
- Serve as technical expert in health record content and documentation requirements.
- Perform reviews of the health record documentation; developing criteria, collecting data, graphing and analyzing results, creating reports and communicating in writing and/or in person to appropriate leadership and groups.
- Obtain appropriate corrective action plans from responsible clinical services directors, when necessary, and recommend improvements or changes in documentation as deemed necessary.
- Adhere to established documentation requirements as outlined by accrediting agencies guidelines, regulations, policy and medical-legal requirements.
- Develop and implement active training/education programs (i.e. seminars, workshops, short courses, informational briefings, and conferences) for all providers to ensure the CDIS program objectives are met.

**NON-DISCRIMINATION POLICY**

Paradigm is an equal opportunity employer and makes all employment decisions, including those related to recruitment, hiring, training, promotion, and recognition of individuals on the basis of their ability and job-related qualifications and without regard to race, gender, religion, national origin, sexual orientation, disability, or any other classification proscribed under applicable federal, state, or local law.

**_
The availability of this position is based on contract award._**

**_

  • Clinical Documentation Specialist

    1 week ago

    San Diego, United States Viakorp Company Full time

    **Job title**: Clinical Documentation Specialist **Location**: San Diego, CA **Schedule**: Monday through Friday 7:30 am to 4:00 pm. **Duties**: - Abstract medical record data and assign codes. - Improve quality and accuracy of medical record documentation. - Develop and update policy memoranda on documentation. - Serve as technical expert in health...

  • Clinical Documentation Specialist

    4 weeks ago

    San Diego, United States Ladgov Corporation Full time

    Job title: Clinical Documentation Specialist Location:San Diego, CA Schedule:Monday through Friday 7:30 am to 4:00 pm.Duties:Abstract medical record data and assign codes.Improve quality and accuracy of medical record documentation.Develop and update policy memoranda on documentation.Serve as technical expert in health record content.Perform reviews, analyze...

  • Clinical Documentation Specialist

    2 weeks ago

    San Diego, United States Ladgov Corporation Full time

    Job title: Clinical Documentation Specialist Location:San Diego, CA Schedule:Monday through Friday 7:30 am to 4:00 pm.Duties:Abstract medical record data and assign codes.Improve quality and accuracy of medical record documentation.Develop and update policy memoranda on documentation.Serve as technical expert in health record content.Perform reviews, analyze...

  • Clinical Documentation Specialist

    1 month ago

    San Diego, United States Ladgov Corporation Full time

    Job DescriptionJob DescriptionJob title: Clinical Documentation Specialist Location:San Diego, CA Schedule:Monday through Friday 7:30 am to 4:00 pm.Duties:Abstract medical record data and assign codes.Improve quality and accuracy of medical record documentation.Develop and update policy memoranda on documentation.Serve as technical expert in health record...

  • Clinical Documentation Specialist

    2 weeks ago

    San Diego, United States Ladgov Corporation Full time

    Job DescriptionJob DescriptionJob title: Clinical Documentation Specialist Location:San Diego, CA Schedule:Monday through Friday 7:30 am to 4:00 pm.Duties:Abstract medical record data and assign codes.Improve quality and accuracy of medical record documentation.Develop and update policy memoranda on documentation.Serve as technical expert in health record...

  • Clinical Documentation Specialist

    1 month ago

    San Diego, United States Ladgov Corporation Full time

    Job title: Clinical Documentation Specialist Location:San Diego, CA Schedule:Monday through Friday 7:30 am to 4:00 pm.Duties:Abstract medical record data and assign codes.Improve quality and accuracy of medical record documentation.Develop and update policy memoranda on documentation.Serve as technical expert in health record content.Perform reviews, analyze...

  • Clinical Documentation Specialist

    1 week ago

    San Diego, United States Ladgov Corporation Full time

    Job title: Clinical Documentation Specialist Location:San Diego, CA Schedule:Monday through Friday 7:30 am to 4:00 pm.Duties:Abstract medical record data and assign codes.Improve quality and accuracy of medical record documentation.Develop and update policy memoranda on documentation.Serve as technical expert in health record content.Perform reviews, analyze...

  • Clinical Quality Improvement Specialist

    1 week ago

    San Diego, United States UC San Diego Health Full time

    Payroll Title: - QLTY IMPV HC SPEC 3 - Department: - PHSO - CLINICAL OPERATIONS - Hiring Pay Scale - $92,000 - $160,000 / Year - Worksite: - Greenwich Drive - Appointment Type: - Career - Appointment Percent: - 100% - Union: - Uncovered - Total Openings: - 1 - Work Schedule: - Days, 8 hour shifts, Monday - Friday**#130310 Clinical Quality Improvement...

  • Clinical Documentation Specialist

    1 month ago

    San Angelo, United States Shannon Health Full time

    Job SummaryThe clinical documentation specialist works collaboratively with physician and coding staff to ensure that the documentation in the medical record accurately reflects the quality and level of care provided. The overall goal of the position is to improve clinical documentation for quality assurance and revenue compliance and integrity.Scope &...

  • Clinical Documentation Specialist

    2 weeks ago

    San Angelo, United States Shannon Health Full time

    Job SummaryThe clinical documentation specialist works collaboratively with physician and coding staff to ensure that the documentation in the medical record accurately reflects the quality and level of care provided. The overall goal of the position is to improve clinical documentation for quality assurance and revenue compliance and integrity.Scope &...

  • Clinical Documentation Specialist

    2 weeks ago

    San Antonio, United States Christus Health Full time

    Job Description Summary: The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG...

  • Clinical Documentation Specialist

    3 weeks ago

    San Antonio, United States Christus Health Full time

    Job Description Summary: The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG...

  • Clinical Documentation Specialist

    3 weeks ago

    San Antonio, United States Christus Health Full time

    **Summary**: The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG assignment and...

  • Clinical Documentation Specialist

    2 months ago

    San Antonio, United States Christus Health Full time

    Job DescriptionSummary:The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG...

  • Clinical Documentation Specialist

    2 months ago

    San Antonio, United States Christus Health Full time

    Job DescriptionSummary:The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG...

  • Clinical Documentation Specialist

    2 months ago

    San Antonio, United States Christus Health Full time

    Job DescriptionSummary:The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG...

  • Clinical Documentation Specialist

    2 months ago

    San Antonio, United States CHRISTUS Childrens Hospital Full time

    Job Description Summary: The Clinical Documentation Specialist (CDS) position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate...

  • Associate Specialist, Document

    1 week ago

    San Diego, United States Neurocrine Bioscience Full time

    Who We Are: At Neurocrine Biosciences, we pride ourselves on having a strong, inclusive, and positive culture based on our shared purpose and values. We know what it takes to be great, and we are as passionate about our people as we are about our purpose - to relieve suffering for people with great needs, but few options. What We Do: Neurocrine Biosciences...

  • Clinical Documentation Specialist

    2 months ago

    San Antonio, United States Christus Health Full time

    **Summary**: The position is responsible for facilitating improvement in the overall quality and completeness of the medical record documentation. The CDS will provide support and expertise through comprehensive assessment and review of inpatient medical records. The CDS will facilitate accurate DRG assignment and obtain appropriate documentation through...

  • Document Specialist

    3 weeks ago

    San Diego, United States Hudson Trading Group LLC Full time

    Job Description Job Description Company Overview: Join our dynamic team at Hudson, a leading player in the spice industry committed to delivering top-quality products to consumers. With our focus on innovation, quality, and sustainability, we're dedicated to shaping the future of safe food. As we continue to expand our operations, we are seeking a meticulous...