Clinical Documentation Specialist
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Job Location:
Fountain Valley, CA - USA
Monthly Salary:
Not Disclosed
Posted on:
2 hours ago
Vacancies:
1 Vacancy
Job Summary
Job Title: Clinical Documentation Specialist
Location: Fountain Valley California/Remote Role
Duration: 3 Months
Job Type: Contract
Note: Applications 360 3M and Iodine highly desired. Top 3 Keywords: 1- Clinical Documentation Integrity (CDI) 2- DRG Assignment & Concurrent Review 3- Epic & 3M 360 CDI Systems
Top Required Skills:
- Concurrent medical record review & clinical documentation improvement
- DRG assignment & coding collaboration
- Clinical communication & physician querying
Must-Have Skills:
- Concurrent review of inpatient medical records for accuracy and completeness
- Strong clinical knowledge to assess severity of illness risk of mortality and quality of care
- Experience identifying principal and secondary diagnoses and procedures
- Ability to assign and reconcile concurrent working DRGs
- Physician query development and compliance with CDI standards
- Strong understanding of coding and reimbursement guidelines (CMS NCHS AHA)
- Proficiency with clinical and collaboration systems (e.g. EPIC 3M 360 Outlook Teams SharePoint)
- Excellent verbal and written communication skills
- Ability to work independently in a remote environment
- Strong attention to detail organization and multitasking abilities
- Strict adherence to HIPAA and patient confidentiality
Nice-to-Have Skills:
- CCDS and/or CDIP certification
- Experience with DRG mismatch analysis and retrospective reviews
- Experience supporting quality metrics patient safety indicators and compliance audits
- Experience using Iodine Zoom or similar clinical review tools
Key Responsibilities & Duties:
- Perform initial and subsequent concurrent CDI reviews for selected admissions and document findings
- Identify documentation clarification opportunities related to diagnosis specificity quality safety and resource utilization
- Assign concurrent working DRGs and collaborate with physicians coders and CDI leadership to finalize DRGs
- Issue compliant physician queries to ensure accurate and complete clinical documentation
- Meet productivity quality compliance and audit performance standards
- Maintain HIPAA compliance follow organizational policies and support special projects as assigned
Requirements:
- MD BS or higher in a healthcare-related field OR CCS-certified coder with strong clinical background
- Active clinical licensure (RN PA NP MD or FMD) and/or CCS certification (required)
- Strong understanding of CDI coding guidelines and reimbursement impact
- Ability to work autonomously and productively in a remote work environment
- English proficiency (read write speak)
Key Skills
- Environment
- Ado
- Carpentry
- Drafting
- Front Office Management
- Airlines
