Clinical Documentation Integrity Specialist, Per Diem
- Roseville, CA
- Permanent
- Full-time
- Associate's/Technical Degree or equivalent combination of education/related experience: Required
- Bachelor's Degree: Preferred
- Three years' clinical experience: Required
- Two years' clinical documentation experience: Required
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): Required
- Current licensed RN, medical provider or equivalent: Required
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): Required
- Foreign Medical Doctor (FMD) or Medical license MD (MD) or Registered Nurse (RN): Required
- Evaluates and assesses medical records of patients, looks for specificity of an illness, the accuracy of the clinician's documentation, coding requirements and documentation of important medical details to ensure the overall quality and completeness of clinical documentation of the patient medical record. Performs coding, working DRG assignment and enters all review activity into tracking software.
- Analyzes and interprets medical records and clinical documentation and formulates appropriate physician queries. Performs follow up on incomplete physician queries to obtain an answer while the patient is still in house. Updates “working DRG” as documentation supports, or physician query answer supports a change in the DRG assignment.
- Reviews quality of medical record and communicates when conflicting data are found, the clinical documentation integrity specialist (CDIS) conveys deficiencies to the department lead for more information to resolve the conflict.
- Keeps abreast of regulatory changes related to documentation, coding and communicate these changes to appropriate staff. Follows documentation guidelines and legal requirements to ensure compliance with federal and state regulatory bodies. Attends ongoing education sessions.
- Acts as a liaison between the medical staff and the coding department. Works collaboratively with physicians and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate clinical diagnosis and level of severity is captured for the level of service rendered to all patients. Attends scheduled physician and care management meetings as requested and reviews requested cases prior to the meetings.
- Performs other job-related duties as assigned.