Job Description

Clinical Documentation Specialist - Clinical

SUMMARY: The Clinical Documentation Improvement Specialist - Clinical will conduct concurrent review of clinical documentation in the medical record to obtain accurate and complete provider documentation for all conditions and procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. Collaborates extensively with physicians, nursing staff, other patient caregivers, and medical records coding staff to improve quality and completeness of documentation of care provided and coded. The Clinical Documentation Specialist-Clinical evaluates admission criteria, conducts concurrent reviews including initial, regular and extended stay reviews on a majority of admissions. Serves as a resource for RN Case Managers and providers to assign the correct patient status and level of care and supports the medical necessity of services. Provide follow-up education to medical staff regarding high-quality clinical documentation guidelines and practices. The position requires strong understanding of the requirements for clinical coding and billing according to the rules of Medicare, Medicaid, and commercial health plans along with knowledge of Interqual and medical necessity criteria.

JOB REQUIREMENTS: This position requires: A) Medical or Nursing graduate or Physician Assistant (PA); B) minimum of three (3) years clinical experience in an acute care setting, preferably in pediatrics; C) Experience in a clinical documentation program and a Clinical Documentation Improvement Specialist (CDIS) certification are preferred. Additional qualifications include: Knowledge of APR-DRG assignment, and clinical conditions or procedures; Demonstrate knowledge of complete and accurate clinical documentation as well as coding and billing practices in all healthcare settings and for all healthcare disciplines. Knowledge of coding conventions, rules, and guidelines; Knowledge of coding and operational implications of ICD-10; Knowledge of medical terminology, disease processes, and pathophysiology. Strong organization, prioritization, critical thinking, and problem-solving skills; Excellent communication, interpersonal skills, analytical and critical thinking skills.

POSITION DETAILS: Full-time, 80 hours per pay period, M-F, 8-5

LOCATION: Madera, CA

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