Job Description

Job Title: Clinical Documentation Specialist

Location: Fountain Valley, CA 92708/Remote

Note: Applications 360, 3M and Iodine highly desired.

Summary of Job:

This position is responsible for initiating and completing the concurrent review of medical records to ensure the information documented accurately reflects the patient's severity of illness, clinical treatment, risk of mortality, and quality and intensity of care. Reviews include verifying that clinical conditions are documented in diagnostic format to ensure appropriate reporting, identifying query opportunities to clarify or validate clinical conditions, assigning principal and secondary diagnoses and/or procedures for appropriate designation of DRG and LOS, and identifying quality indicators and codes that contribute to reportable quality metrics and compliance standards.

Must-have/Required skills:

• Computer, internet, and word processing experience required.
• Excellent verbal and written communication skills.
• Collaborative interaction and effective education skills with the medical staff and ancillary departments to collegially discuss clinical aspects of care is vital.
• Ability to perform accurate patient chart review analysis and data collection.
• Ability to prioritize essential functions and multitask utilizing multiple resources and applications (including but not limited to: 3M 360, EPIC, Outlook, Iodine, Microsoft Teams, Zoom, SharePoint)
• Ability to demonstrate integrated knowledge of job specific competencies.
• Follow company and department policies, procedures, and directives.
• Maintain HIPAA and patient confidentiality at all times.
• Ability to work autonomously and productively in a remote work environment while adhering to all company security policies and remote-work agreement.
• Ability to interact in a positive and constructive manner.
• Completes initial concurrent review process and subsequent reviews for all selected admissions to initiate the clinical documentation review process. Documents findings and identifies clinical documentation clarification(s) opportunities regarding diagnosis specificity, documentation inconsistencies/conflicts, quality of care/patient safety, and resource utilization.
• Identifies principal diagnosis, secondary diagnoses, and procedures to assign a concurrent working DRG based on the clinical picture. Collaborates with medical staff, medical records coder, and CDI leadership to determine a final DRG that supports an accurate reflection of severity of illness, risk of mortality, and utilization of resources. Reconciles DRG mismatches with coders and CDI coordinators in a respectful and positive manner.
• Queries the medical staff to obtain accurate and complete chart documentation that appropriately supports the severity of illness. Maintains department, organization, and industry compliance in query process.
• Meets department productivity for CDI reviews inclusive of initial reviews, secondary reviews, retrospective reviews, DRG mismatch analysis, and query follow-ups.
• Meets minimum threshold in monthly audits for quality, compliance, workflow, and outcomes.
• Employs strong understanding of coding guidelines and working knowledge of CMS, NCHS, and AHA guidelines and their impact on reimbursement, quality metrics, utilization management, and physician/health system statistics.
• Takes responsibility for various projects as assigned by management and performs any additional/miscellaneous duties (not inclusive of job description) as requested by the management team within the scope of knowledge/ability.
• MD, BS or higher in healthcare related field, or licensed coder (CCS) with strong clinical knowledge base and background.
• Clinical licensure (RN, PA, NP, MD, or FMD) and/or Coding certification (CCS) required.

Nice-to-have skills:

• CCDS and/or CDIP certification preferred.

Key responsibilities and duties:

• Completes initial concurrent review process and subsequent reviews for all selected admissions to initiate the clinical documentation review process.
• Documents findings and identifies clinical documentation clarification(s) opportunities regarding diagnosis specificity, documentation inconsistencies/conflicts, quality of care/patient safety, and resource utilization.
• Identifies principal diagnosis, secondary diagnoses, and procedures to assign a concurrent working DRG based on the clinical picture.
• Collaborates with medical staff, medical records coder, and CDI leadership to determine a final DRG that supports an accurate reflection of severity of illness, risk of mortality, and utilization of resources.
• Reconciles DRG mismatches with coders and CDI coordinators in a respectful and positive manner.
• Queries the medical staff to obtain accurate and complete chart documentation that appropriately supports the severity of illness.
• Maintains department, organization, and industry compliance in query process.
• Meets department productivity for CDI reviews inclusive of initial reviews, secondary reviews, retrospective reviews, DRG mismatch analysis, and query follow-ups.
• Meets minimum threshold in monthly audits for quality, compliance, workflow, and outcomes.
• Employs strong understanding of coding guidelines and working knowledge of CMS, NCHS, and AHA guidelines and their impact on reimbursement, quality metrics, utilization management, and physician/health system statistics.
• Takes responsibility for various projects as assigned by management.
• Performs any additional/miscellaneous duties (not inclusive of job description) as requested by the management team within the scope of knowledge/ability.
• Other duties as assigned.

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