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Clinical Documentation Specialist

Company: Air Combat Effectiveness Consulting Group, LLC
Location: San Gabriel
Posted on: November 21, 2022

Job Description:

Posted Date 4 days ago (8/26/2022 8:26 PM) Requisition ID req15966 Facility San Gabriel Valley Medical Center # of Openings 1 Shift Days Category Health Information Management Position Type Regular Full-Time OverviewPOSITION SUMMARYThe Clinical Documentation Improvement Specialist is required to have a full understanding and active participation in fulfilling the mission, vision and values of San Gabriel Valley Medical Center. The employee shall support San Gabriel Valley Medical Center's strategic plan and the goals and direction of the department Performance Improvement Plan (PIP).The Clinical Documentation Improvement Specialist, under minimal direction, will provide active concurrent/retrospective review, provide feedback, and educate clinical care providers to improve the documentation of all conditions, treatments, and care plans within the health record to accurately reflect the condition of the patient and promote patient care. In addition, documentation should reflect documentation associated with MS-DRG and APR-DRG assignment, case mix index, severity of illness, risk of mortality, physician profiling, hospital profiling, and reimbursement rules. The Clinical Documentation Improvement Specialist must at all times safeguard and protect the patient's right to privacy by ensuring that only authorized individuals have access to the patient's medical information and that all releases of information are in compliance with the request, authorization, company policy and HIPAA regulations.ResponsibilitiesDUTIES AND RESPONSIBILITIES
The Clinical Documentation Improvement Specialist job summary includes but is not limited to:
--- Conducts initial and extended-stay concurrent review on selected admissions
--- Code and abstract inpatient admissions to generate working-DRG
--- Demonstrate successful completion of ongoing proficiency and compliance with regulatory requirements
--- Identifies co-morbidities and complications and documents appropriately
--- Queries the medical staff and other clinical caregivers as necessary via written/verbal communication to obtain accurate and complete documentation
--- Identifies potential quality, severity of illness, risk of mortality, hospital/physician profiling, and reimbursement issues or missing documentation
--- Communicate documentation issues clearly and succinctly to clinical care providers
--- Demonstrates an understanding of complications, comorbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on DRG, and the ability to impart these concepts and knowledge to physicians and other health care members
--- Makes an effort to capture all potential secondary diagnoses
--- Act as the liaison between clinical care providers and coding professionals
--- Identifies documentation issues and trends, and reports them to the appropriate manager per hospital reporting requirements
--- Interact with coding team as documentation issues are identified through the coding process for discussion with clinical staff--- Provides ongoing education to physicians and other clinical care providers, related to documentation, changes in coding, compliance issues, profiling concerns, and reimbursement changes
--- Interact with Case Management as they perform admission and continued stay review
--- Monitor changes in law, regulations, rules, and code assignment that impact documentation and reimbursementQualificationsMINIMUM QUALIFICATIONS--- Certified Coding Specialist credentials from AHIMA
--- A minimum of 3 years coding experience in a hospital Health Information Management Department
--- Preferred 1 year experience with acute care hospital CDI--- RN, BSN, RHIA, RHIT, or CCS required
--- Certified Coding Specialist credentials from AHIMA--- Advance knowledge of ICD-10-CM/PCS Official Guidelines for Coding and Reporting
--- Advance knowledge of AHA Coding Clinic for ICD-10-CM/PCS
--- Advance knowledge of AHA Coding Clinic for HCPCS
--- Advance knowledge of HIPAA regulations and to complete work in compliance of these and other standards
--- Ability to read and comprehend advance medical terminology
--- Effective verbal and written communication skills
--- Effective organizational skills
--- Ability to use fax, copier, scanner and multiline phone system and other required work tools
--- Ability to learn new equipment, systems and required processes in a fast paced environment
--- Ability to work professionally, effectively, and efficiently in a team environment with customers, management and co-workers Sorry the Share function is not working properly at this moment. Please refresh the page and try again later.

Keywords: Air Combat Effectiveness Consulting Group, LLC, San Gabriel , Clinical Documentation Specialist, Healthcare , San Gabriel, California

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