Clinical Documentation Specialist/Coder III

5 days ago

Corona, California, United States KPC GLOBAL MEDICAL CENTERS INC. Full time
Job Summary

The Clinical Documentation Specialist/Coder III is a key member of our team at KPC Global Medical Centers Inc., responsible for conducting thorough and accurate reviews of inpatient medical records. This role requires a strong clinical knowledge and understanding of disease processes, as well as excellent written and verbal communication skills.

Key Responsibilities
  • Conduct concurrent and retrospective reviews of inpatient medical records to ensure accurate and complete clinical documentation.
  • Work closely with medical staff to facilitate appropriate clinical documentation of patient care.
  • Abstract and code diagnostic and procedural information for inpatient services and surgery medical records using the current version of International Classifications of Diseases.
  • Enter coded data and other abstracted data into the electronic information system.
  • Clarify ambiguous documentation and optimize DRG coding to ensure accurate reimbursement.
  • Participate in chart review projects as assigned.
Requirements
  • Medical Graduate, PA, RN, LVN, RHIT or CCS with current valid license/certification and relevant education.
  • CCS Certification Required.
  • CDIP and/or CCDS Certification Preferred.
  • Minimum of 2+ year's clinical experience in an acute care setting or 5 years of acute care inpatient coding.
  • Knowledge of care delivery documentation systems and related medical record documents.
  • Knowledge of the elements of disease processes and related procedures.
  • Strong clinical knowledge and understanding of pathology/physiology of disease processes.
  • Excellent written and verbal communication skills.
  • Excellent critical thinking skills.
  • Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, and hospital management staff.
  • Working knowledge of inpatient admission criteria, preferred.
  • Ability to work independently in a time-oriented environment.
  • Computer literacy and familiarity with the operation of basic office equipment.
  • Assertive personality traits to facilitate ongoing physician communication.
  • Working knowledge of Medicare reimbursement system and coding structures, preferred.
Benefits
  • Medical, dental, and vision coverage for all full-time and part-time employees.
  • Medical is 100% employer-paid, including dependents.
  • Employee Stock Ownership Program.
  • Basic Life and AD&D.
  • 401k plan with company match.
  • Generous PTO plan.
  • Pet Insurance Discount Program.
  • Employee Discount Program.

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