Completes clinical review of medical record for identified patients in the required timeframe. Communicates with physicians face to face or via clinical documentation inquiry forms to clarify information, obtain needed documentation and educate physicians for appropriate clinical documentation that will accurately reflect patient severity of illness and risk of mortality. Follows up with appropriate health team members to ensure accurate and complete documentation in the medical record. Demonstrates an understanding of complications, HACs, PSIs, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, and impact of procedures on DRG; and is able to share this knowledge to physicians and other health team members. Confers with physicians, nursing, case management, quality and other clinical caregivers to explain the importance of clear and concise documentation. Confers with hospital coding staff to ensure appropriate DRG and completeness of supporting documentation. Collaborates with coders to ensure AR days remain in target range. Reviews records upon coding request to confirm DRG assignment or need to follow up with physician regarding incomplete documentation. Maintains accurate data in 3M 360 Encompass CAC tool. Provides reports and identifies trends, as needed. Provides required/requested information, inappropriate resource utilization, statistical data or reports for Hospital Administration, Quality team, and Medical Coding. Achieves and maintains current knowledge and understanding of ICD-10 CM & PCS coding and DRG systems, through participation in education and training, including reading and comprehension of AHIMA Coding Clinic & coding guidelines.
Minimum 2years' working experience as a Clinical Documentation Specialist, preferrably in an Academic Medical Center. Ability to effectively communicate to physicians and staff the necessity and appropriateness of clinical documentation based on patient status, disease states treated during the hospital stay, and procedures performed. Ability to effectively communicate the medical necessity, appropriateness of care, linking of clinical criteria and use of appropriate verbiage documented during an acute care hospitalization. Skills in setting priorities that accurately reflect the relative importance of job responsibilities. Skill in abstracting and interpreting medical information from patient records. Working knowledge of laws, rules and regulations regarding Medicare, Medi-Cal and all other payors. Strong clinical knowledge to understand and communicate medical diagnosis and courses of treatment to professional and non-professional personnel. Immediate knowledge of computer word processing, database programs and ability to write reports and do graphical analysis.
Certification/License: RN, MD, or other related degree required: BS in health related field, CCDS, CDIP, CCS or other coding certification preferred.
Location/Region: Los Angeles, CA