Clinical Documentation Improvement Specialist

4 weeks ago

Pasadena, United States Kaiser Permanente Full time

**Job Summary**:
This position uses clinical knowledge of documentation requirements to improve overall health record quality, capture severity, acuity, and risk of mortality. This position includes the ability to perform concurrent and/or retrospective reviews of inpatient health records to evaluate clinical documentation for integrity and proper documentation of patient care. In addition, incumbent will need to have expertise in understanding the clinical documentation required for the completeness of the patient health record using a multidisciplinary team approach. The specialist will work in conjunction with the medical staff to facilitate appropriate clinical documentation of patient care.

**Essential Responsibilities**:

- Responsible for performing Clinical Documentation Improvement (CDI) chart reviews (concurrent, pre-bill and retrospective) for improving overall quality and completeness of clinical documentation for inpatient accounts.
- Facilitate modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and health records coding staff to improve quality, accuracy, and completeness of clinical documentation in real-time.
- Monitors the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcome data.
- Communicates with members of the patient care team on clinical documentation improvement strategies and workflows, including a real-time physician escalation process and real-time concurrent notifications (utilization review, quality and risk management).
- Validates Present on Admission (POA) indicators are verified and clearly documented for coding while the patient is still in-house.
- Reviews clinical issues with medical coding staff to help them identify diagnoses that impact severity of illness (SOI) and risk of mortality (ROM) indicators for each patient. Serves as an expert resource in reviewing all health records in support of consistent documentation for all payer types (i.e. Centers for Medicare&Medicaid Services (CMS), Medicare-Advantage, etc.) to assure complete and accurate diagnosis and procedure capture and coding.
- **Concurrent Reviews include**:

- Reviews for completeness, contradictions, omissions, and accuracy of medical, surgical, pathological, pharmaceutical, diagnostic, and procedural documentation.
- Identifies Do Not Bill Events (DNBE), Hospital Acquired Conditions (HAC), more definitive diagnosis, procedures, and quality indicators by communicating with Risk Management, Quality Management, Utilization Management, and Infection Control to address related issues.
- Assists with training on clinical documentation improvement practices to physicians and key stakeholders.
- Monitors verbal and written queries and conducts follow-up on queries and escalates as needed.
- Other duties as assigned.

**Basic Qualifications**:
Experience
- Minimum three (3) years in-patient clinical or coding experience.

Education
- Associate degree in a clinical/healthcare related field or two (2) years experience in a directly related field required.
- High School Diploma or General Education Development (GED).

License, Certification, Registration
- Documentation Improvement Practitioner Certificate OR Clinical Document Specialist Certificate

**Additional Requirements**:

- Comprehensive understanding of a health records clinical content.
- Ability to effectively communicate with physicians and other healthcare providers.
- Excellent written, organizational and analytical skills required.
- Competent computer skills in MS Word, Excel and PowerPoint and clinical systems required, familiar with 3MTM Coding and
- Reimbursement Systems, Ingenix, etc.
- Excellent critical thinking skills, ability to prioritize work; strong communication skills and must be able to interact with all levels of healthcare professions.
- Must be able to work in a Labor/Management Partnership environment.

**Preferred Qualifications**:

- Minimum two (2) years of experience as a Clinical Documentation Specialist preferred.
- Familiar with coding classifications systems such as, but not limited to ICD-9 CM, ICD-10 MS-DRG, HCC preferred.
- Licensure, certification, registration, related to clinical practice preferred.
- Current credentialing from AHIMA accredited coding certification program for Certified Coder Specialist (CCS) or Registered Health.
- Information Technician (RHIT) and/or Registered Health Information Administrator (RHIA) preferred.
- Graduate from a school of nursing, preferably a BSN preferred.
- Graduate from an accredited Health Information Technology/Informatics Program preferred.
- Completion of an accredited health information coding program, with certification offered by AHIMA (American Health Information.
- Management Association) preferred.

PrimaryLocation : California,Pasadena,Walnut Center - Regional Offices

HoursPerWeek : 40

Shift : Day

Workdays : Mon, Tue, We

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