CDIS - Clinical Doc Improvement Specialist - Hemet, CA

Job Description

Job Description

Location : Central Business Office

Job Title : Clinical Documentation Specialist (CDS) / Coder III

Department : Health Information Management

Reports to : Director OF Coding and CDI operations

Completion Date : SUMMARY

The Clinical Documentation Specialist (CDS) / Coder III is responsible conducting clinically based concurrent and retrospective reviews of inpatient medical

records. This review is to evaluate that the clinical documentation is reflective of quality of care outcomes and reimbursement compliance for acute care

services provided. The CDS will work closely with the medical staff to facilitate appropriate clinical documentation of patient care. The CDS / Coder III abstracts

and codes the diagnostic and procedural information for Inpatient Services and Surgery medical records utilizing the current version of International

Classifications of Diseases in accordance with regulatory agencies and hospital specific guidelines. The CDS / Coder III enters the coded data and other

abstracted data from the medical record into the electronic information system. This position assumes primary responsibility for clarifying ambiguous

documentation, DRG optimization with the primary role in assisting medical staff members with improving quality of documentation and serves as a mentor to

all level of Coders and CDIs. Participates in chart review projects as assigned.

REQUIREMENTS

RESPONSIBILITIES AND DUTIES :

• Understands and is able to incorporate hospital philosophies into the department’s operational plan and goals and assures staff members

understand philosophies.

HIPAA, medical staff regulations, and hospital policies.

effective operations.

Aware of Medicare reimbursement methodology for inpatient services as it pertains to clinical documentation and coding.

consideration prior to instituting changes, deletions or additions of processes.

status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.

of the Center for Medicare and Medicaid Services.

patient caregivers and Health Information Management staff.

admission, on the working days.

documentation issues / omissions / discrepancies and assists physicians with improving documentation in the medical record.

documentation to support intensity of services and level of acuity of the patient.

EDUCATION & EXPERIENCE REQUIREMENTS :

SKILLS & ABILITIES REQUIREMENTS :

and / or organizational quality improvement goals.

improvement of services.

PHYSICAL REQUIREMENTS :