Clinical Documentation Specialist - Clinical Research - Part Time 8 Hours Day

POSITION SUMMARY

The Clinical Documentation Specialist monitors the quality of medical records and document by abstracting data entering multiple stroke and research databases and ensuring quality improvement of data collection on stroke performance metrics and nursing metrics. This also includes assuring the medical records contain the mandated core measure data used to report to multiple regulatory agencies. The Clinical Documentation Specialist facilitates concurrent modifications to clinical documentation to ensure adequate information is included in the medical record about diagnosis treatment and followups. They communicate and educate physicians nurses coding staff and other healthcare professionals to clarify issues and assure missing information is included to meet policies and regulations. They assist with clinical research recruitment consenting data collection abstraction and followup for clinical research trials.

ESSENTIAL JOB FUNCTIONS AND CORE RESPONSIBILITIES

Education

• Assists nursing staff in preparation for DNV survey and post survey findings.
• Concurrently reviews a patients medical records to ensure documentation is accurate as well as up to date with the latest information on a patients diagnosis and educates staff on any missing documentation elements.
• Following up with doctors and nurses where needed to complete an individual patients records.
• Coaches and mentors staff to ensure optimal outcomes.
• Provides staff education as required by LA County EMS DNV and the American Stroke Association.
• Partners with stroke team to develop patient education resources and provides nurses support with providing stroke patient education.
• Participates in stroke education/training for members of the healthcare team including stroke scales stroke protocols and guidelines best practices and emerging treatments.
• Collaborate and participate in stroke prevention community outreach efforts.

Clinical Practice and Collaboration

• Provides ongoing patient followup calls post discharge with the goal of improving quality of life for the patient and prevention of readmissions to the hospital.
• Conducts 7day stroke patient satisfaction calls post discharge.
• Conducts 90day followup calls for patients that receive neuro intervention and calculation of Modified Rankin Scale (MRS)
• Collaboration with physicians and personnel from all departments and specialty areas to optimize stroke care in accordance with stroke guidelines.

Quality Improvement and Data

• Assistance with post survey auditing and metrics.
• Data abstraction entry and submission to Get with The Guidelines Stroke.
• Design build and generate reports from data abstracted from patient records.
• Provide more complex information for documentation changes to assure core measures are met.
• Demonstrate proficient use of excel and other databases needed to store and abstract data.
• Recognizes opportunities for improvement by using strong criticalthinking skills. Uses critical thinking clinical experience and sound judgement to adjust documentation to meet regulatory requirements.
• Initiates chart review audits to validate quality outcome data for nursing and stroke program metrics.
• Collaborates with Stroke Medical Director Stroke Coordinator Stroke Navigator and Clinical Research Manager to initiate performance improvement initiatives to improve processes that will ultimately improve care.
• Performs other duties as assigned.

Clinical Research

• Identifies patient eligibility for available research studies.
• Collaborates with the Clinical Research Team in consenting patients for research studies.
• Oversees documentation for the stroke patients assuring consistency accuracy to meet clinical research and regulatory requirements.

Physicians as Partners

• Demonstrates effective communication and behaviors that support teamwork in a professional manner.
• Works with the Stroke Program Medical Director and stroke team to continue to improve our overall patient care.
• Acts as a role model and leader in addressing physician issues and concerns.
• Promotes interdisciplinary coordination of patient care.
• Ensures that patients needs are being met and patients/families are satisfied with the care they are receiving.

USC is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin protected veteran status disability or any other characteristic protected by law or USC policy. USC observes affirmative action obligations consistent with state and federal law. USC will consider for employment all qualified applicants with criminal records in a manner consistent with applicable laws and regulations including the Los Angeles County Fair Chance Ordinance for employers and the Fair Chance Initiative for Hiring Ordinance and with due consideration for patient and student safety. Please refer to theBackground Screening Policy Appendix Dfor specific employment screen implications for the position for which you are applying.

We provide reasonable accommodations to applicants and employees with disabilities. Applicants with questions about access or requiring a reasonable accommodation for any part of the application or hiring process should contact USC Human Resources by phone ator by email at. Inquiries will be treated as confidential to the extent permitted by law.

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