Overview Riverside University Health System-Medical Center has several opportunities for Clinical Documentation Improvement Specialists. These positions have either a Monday-Friday or a Tuesday - Saturday, 9/80 work schedule, and offer a hybrid remote schedule, one day per week in the office (during training, more time in the office may be required). Ideal candidates will have significant professional coding and abstracting experience in an acute care hospital, along with applicable education/certification(s), and experience utilizing EPIC and 3M Clinical Documentation Integrity Services. Classification Concept The CDI Specialist reviews inpatient and outpatient medical-record documentation to assure completeness, clarity, accuracy, and overall quality in accordance with Coding and Clinical Documentation Improvement goals. This class is responsible for concurrent clinical documentation review with an emphasis on completeness and accuracy of healthcare provider documentation related to types of medical services provided and the level of patient illness severity throughout hospital admission/discharge. The Clinical Documentation Improvement (CDI) Specialist is experienced in clinical documentation review and capable of implementing methods of improving the accuracy, specificity, and completeness of patient-care documentation. The major role of a CDI Specialist is to serve as an institutional subject matter expert and as a resource for interpretation and application of coding rules and regulations; and, when necessary, write physician queries to obtain additional documentation or clarification. The incumbent provides guidance to physicians, clinicians, and coders regarding documentation requirements. A CDI Specialist is expected to possess an in-depth understanding of the substantive contents of a medical record, including extensive knowledge of a wide variety of specialized medical terminology, as well as medical diagnosis, treatment plans, and protocols. Role Highlights Riverside University Health System-Medical Center consistently receives national recognition for its progressive and innovative care, as well as being known as one of the top employers in the region. The 439-bed Medical Center is a designated Stroke Center, Level II Trauma Center, and the only Pediatric ICU in the region. For more information on RUHS-Medical Center, please visit . Key Responsibilities Complete admission reviews of patients' records within 24 hours of admission to evaluate and analyze documentation to assign the principal diagnosis, pertinent secondary diagnoses and procedures for accurate and optimal CMS-Diagnostic Related Group (CMS-DRG) assignment. Initiate and perform concurrent documentation reviews of selected inpatient and outpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists and conduct follow-up reviews as necessary. Develop and implement methods of improving the clarity, accuracy and completeness of clinical documentation; monitor and evaluate coding outcomes and provide periodic status to medical center departments and committees. Communicate with and serve as a resource for physicians, nurses and other healthcare providers to facilitate complete and accurate documentation of the patient record; query physicians regarding missing, unclear or conflicting medical record documentation and obtain additional documentation; keep physician leaders informed of pertinent data, documentation trends and opportunities for learning and improvement related to documentation integrity. Code a wide variety of procedures and primary and secondary diagnoses according to ICD-10-CM and CPT-4; prepare pertinent data from medical charts for various studies and reports to regulatory agencies. Collect data for performance improvement and report findings; participate in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement. Participate in revenue cycle meetings, providing data relative to reimbursement concerns; educate physicians and healthcare providers regarding documentation matters related to coding, billing and reimbursements. Qualifications – Options OPTION I Education: Bachelor’s degree in nursing from an accredited college or university. Experience: Three years as a registered nurse in an acute care hospital. License/Certificate: Current California RN license; Basic Life Support (BLS), Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) certificates from the American Heart Association for professional healthcare providers.
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