Lead 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 or equivalent combination of education/related experience: Required
- Five years' clinical documentation integrity experience: Required
- Three years' clinical experience: Required
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): Required within two years of hire
- 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
- Acts as a liaison between medical staff, other departments, and the CDI team to relay feedback. Attends onsite meetings in person to represent CDI. Responsible for new hire training. Responsible for running reports. Responsible for denials review when required. Supports assigned market but will support other markets in the region as needed.
- 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.
- Analyzes and interprets medical records and clinical documentation and formulates appropriate physician queries. Reviews quality of medical record and communicates when conflicting data are found, the clinical documentation specialist (CDS) conveys deficiencies to the healthcare provider for more information to resolve the conflict.
- Acts as a liaison between the medical staff and other departments. Works collaboratively with physicians and other department 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.
- Keeps abreast of regulatory changes related to documentation and coding and communicates these changes to appropriate staff. Follows documentation guidelines and legal requirements to ensure compliance with federal and state regulatory bodies.
- Performs other job-related duties as assigned.