Clinical Documentation Improvement Specialist

Complete admission reviews of patients records within 24-hours of admission to evaluate and analyze documentation in order to assign the principal diagnosis pertinent secondary diagnoses and procedures for accurate and optimal CMS-Diagnostic Related Group (CMS-DRG) assignment.

Initiate and perform concurrent documentation reviews of selected inpatient and outpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists and conduct follow-up reviews as necessary.

Develop and implement methods of improving the clarity accuracy and completeness of clinical documentation; monitor and evaluate coding outcomes and provide periodic status to medical center departments and committees.

Communicate with and serve as a resource for physicians nurses and other healthcare providers to facilitate complete and accurate documentation of the patient record; query physicians regarding missing unclear or conflicting medical record documentation and obtain additional documentation; keep physician leaders informed of pertinent data documentation trends and opportunities for learning and improvement related to documentation integrity.

Code a wide variety of procedures and primary and secondary diagnoses according to the applicable International Classification of Diseases (i.e. ICD-10-CM or subsequent adaptation) coding system and CPT-4 procedural coding system; prepare pertinent data from medical charts according to criteria established by the Office of State Wide Hospital Planning and Development (OSHPD) and the Medical Audit Committee or individual physicians for various studies statistical indexing and preparation of summary reports to various regulatory agencies.

Collect data for performance improvement and report findings and outcomes; participate in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.

Participate in revenue cycle meetings providing data relative to reimbursement concerns; educate physicians and healthcare providers regarding documentation matters related to coding billing and reimbursements.

OPTION I
Education: Graduation from an accredited college or university with a bachelors degree in nursing.

Experience: Three years as a registered nurse in an acute care hospital. One year ofinpatient CDI experience strongly preferred.

License/Certificate: Must possess and maintain a current valid license to practice as a Registered Nurse in the State of California.

Possession of valid Basic Life Support (BLS) Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) certificates issued by the American Heart Association for professional healthcare providers.

OPTION II
Education: Graduation from an accredited college or university with a bachelors degree in health information management health information technology or a related field to the assignment. (Additional qualifying experience may substitute for the required education on the basis of one year of full-time experience equaling 30 semester or 45 quarter units of the required education).

Experience: Four years of professional coding and abstracting medical records in a healthcare setting. One year ofinpatient CDI experience strongly preferred.

Certificate: Possession of valid certification as a Certified Coding Specialist (CCS) Registered Health Information Technician or Registered Health Information Administrator issued by the American Health Information Management Association.

OPTION III
Education: Completion of Doctor of Medicine degree.

Experience: One year of clinical documentation improvement experience in a healthcare setting. One year ofinpatientCDI experience strongly preferred.

Certificate: Possession of valid certification as a Certified Coding Specialist (CCS) Registered Health Information Technician or Registered Health Information Administrator issued by the American Health Information Management Association. Certification in Clinical Documentation preferred.

ALL OPTIONS
Knowledge of: Coding abstracting and terminology systems such as International Classification of Diseases Clinically Modified (ICD-10) and Current Procedural Terminology (CPT- 4); comprehensive medical terminology covering a wide variety of medical specialties; clinical documentation standards; federal state and local laws and regulations governing professional aspects of nursing; payor source documentation requirements and governmental regulations affecting reimbursement.

Ability to: Analyze and interpret the technical elements of a medical chart; analyze code and abstract complex technical data from medical records covering a wide variety of medical specialties utilizing an encoder and electronic abstracting system; prepare and maintain concise and complete records and reports; establish and maintain effective working relationships with physicians patients and fellow employees; effective communication skills.

This recruitment is open to all applicants.

For additional information about this recruitment contact:
Angela Levinson
or

APPLICATION INFORMATION

Veterans Preference
The County has a Veterans Preference Policy applicable to new hires. To qualify upload a copy of your (or your spouses) Member-4 Form DD-214 indicating dates of service and a copy of your spouses letter of disability (if applicable) with your application. For privacy reasons it is recommended that you remove your social security information from the document(s). A Human Resources Representative will review the materials and determine if you qualify for veterans Veterans Preference Policy C-3 is available here: Accommodations
The County of Riverside is committed to providing reasonable accommodation to applicants as required by the Americans with Disabilities Act (ADA) and Fair Employment and Housing Act (FEHA). Qualified individuals with disabilities who need a reasonable accommodation during the application or selection process should contact the recruiter for the position noted above. For additional information and/or to obtain the appropriate form for requesting a reasonable accommodation please visit the Disability Access Office web page located at: of Education
If using education to qualify or when requested by the recruiter upload a copy of any license(s) official/unofficial transcript(s) degrees and/or related employment documents to your NeoGov account at the time of application and before the closing date. Official or unofficial transcripts will be accepted.

If your education was completed outside of the United States you will need to provide a copy of your Foreign Education Equivalency evaluation from a member of the National Association of Credential Evaluation Services (NACES) or Association of International Credential Evaluators Inc. (AICE).

Work Authorization Requirement
Applicants must be legally authorized to work in the United States at the time of application. The County of Riverside does not participate in visa sponsorship programs including H1-B visas and will not provide sponsorship for any employment-based visas.

Equal Opportunity Employer
The County of Riverside is an Equal Opportunity Employer. It is the policy of the County of Riverside to provide equal employment opportunities for all qualified persons. All applicants will be considered without regard to race color religion sex national origin age disability sexual orientation gender gender identity gender expression marital status ancestry medical condition (cancer and genetic characteristics) genetic information or denial of medical and family care leave or any other non-job-related factors.

Pre-Employment
All employment offers are contingent upon successful completion of pre-employment requirements including a criminal background investigation which involves fingerprinting. (A felony or misdemeanor conviction may disqualify the applicant from County employment). A pre-employment physical examination and background check may be required.

Probationary Period
As an Approved Local Merit System all County of Riverside employees except those serving At Will are subject to the probationary period provisions as specified in the applicable Memorandum of Understanding County Resolution or Salary Ordinance. Temporary and Per Diem employees serve at the pleasure of the agency/department head.

General Information
Current County of Riverside and/or current employees of the hiring department may receive priority consideration. Qualified candidates may be considered for future County vacancies.

Job postings may close without notice based on application volume. Submit your complete application by the recruitment close date; no late applications are accepted. Ensure all relevant experience/education is reflected on your application/resume as a failure to demonstrate position requirements may disqualify applicants. A description of job duties directly copied from the job classification or job posting will not be considered.

Please read and follow any special application instructions on this posting. Click the Apply link located on this page to submit your application. For additional instructions on the application process examinations Veterans preference pre-employment accommodation or other employment questions please refer to our web site .

If you are experiencing technical problems you may contact the applicant support desk Monday through Friday 6 am to 5 pm Pacific Time at or toll-free 1-.