Description : Job Summary : This position uses clinical knowledge of documentation requirements to improve overall health record quality, capture severity, acuity, and risk of mortality.
This position includes the ability to perform concurrent and / or retrospective reviews of inpatient health records to evaluate clinical documentation for integrity and proper documentation of patient care.
In addition, incumbent will need to have expertise in understanding the clinical documentation required for the completeness of the patient health record using a multidisciplinary team approach.
The specialist will work in conjunction with the medical staff to facilitate appropriate clinical documentation of patient care.
Essential Responsibilities : Responsible for performing Clinical Documentation Improvement (CDI) chart reviews (concurrent, pre-bill and retrospective) for improving overall quality and completeness of clinical documentation for inpatient accounts.
Facilitate modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and health records coding staff to improve quality, accuracy, and completeness of clinical documentation in real-time.
Monitors the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcome municates with members of the patient care team on clinical documentation improvement strategies and workflows, including a real-time physician escalation process and real-time concurrent notifications (utilization review, quality and risk management).
The candidate in this position will be instrumental with enhancing the overall quality completeness and accuracy of hospital health record documentation.
Validates Present on Admission (POA) indicators are verified and clearly documented for coding while the patient is still in-house.
Reviews clinical issues with medical coding staff to help them identify diagnoses that impact severity of illness (SOI) and risk of mortality (ROM) indicators for each patient.
Serves as an expert resource in reviewing all health records in support of consistent documentation for all payer types (i.
e. Centers for Medicare&Medicaid Services (CMS), Medicare-Advantage, etc.) to assure complete and accurate diagnosis and procedure capture and coding.
Concurrent Reviews include : Reviews for completeness, contradictions, omissions, and accuracy of medical, surgical, pathological, pharmaceutical, diagnostic, and procedural documentation.
Identifies Do Not Bill Events (DNBE), Hospital Acquired Conditions (HAC), more definitive diagnosis, procedures, and quality indicators by communicating with Risk Management, Quality Management, Utilization Management, and Infection Control to address related issues.
Assists with training on clinical documentation improvement practices to physicians and key stakeholders.Monitors verbal and written queries and conducts follow-up on queries and escalates as needed.
Other duties as assigned. Basic Qualifications : Experience Minimum three (3) years in-patient clinical or coding experience.
Education Associate degree in a clinical / healthcare related field or two (2) years experience in a directly related field required.
High School Diploma or General Education Development (GED). License, Certification, Registration Documentation Improvement Practitioner Certificate OR Clinical Document Specialist Certificate Additional Requirements : Comprehensive understanding of a health records clinical content.
Ability to effectively communicate with physicians and other healthcare providers.Excellent written, organizational and analytical skills petent computer skills in MS Word, Excel and PowerPoint and clinical systems required, familiar with 3MTM Coding andReimbursement Systems, Ingenix, etc.
Excellent critical thinking skills, ability to prioritize work; strong communication skills and must be able to interact with all levels of healthcare professions.
Must be able to work in a Labor / Management Partnership environment. Preferred Qualifications : Minimum two (2) years of experience as a Clinical Documentation Specialist preferred.
Familiar with coding classifications systems such as, but not limited to ICD-9 CM, ICD-10 MS-DRG, HCC preferred.Licensure, certification, registration, related to clinical practice preferred.
Current credentialing from AHIMA accredited coding certification program for Certified Coder Specialist (CCS) or Registered Health.
Information Technician (RHIT) and / or Registered Health Information Administrator (RHIA) preferred. Graduate from a school of nursing, preferably a BSN preferred.
Graduate from an accredited Health Information Technology / Informatics Program pletion of an accredited health information coding program, with certification offered by AHIMA (American Health Information.
Management Association) preferred. Primary Location : California,Pasadena,Walnut Center - Regional Offices Scheduled Weekly Hours : 40 Shift : Day Workdays : Mon, Tue, Wed, Thu, Fri Working Hours Start : 08 : 00 AM Working Hours End : 04 : 30 PM Job Schedule : Full-time Job Type : Standard Employee Status : Regular Employee Group / Union Affiliation : NUE-SCAL-02NUENon Union Employee Job Level : Individual Contributor Department : Regional Offices - Pasadena - Clinical Doc lmprov Codng Svc - 0808 Pay Range : $109600 - $141790 / hour The ranges posted above reflect the location in the job posting.
The salary range may vary if you reside in a different location or state than the location posted. Travel : No At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do.
We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work.
Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing.
Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.
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