Registered Nurse Clinical Documentation Specialist Los Angeles, CA
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Job Location:
Los Angeles, CA - USA
Monthly Salary:
Not Disclosed
Posted on:
Yesterday
Vacancies:
1 Vacancy
Job Summary
Job Description
Summary:
The Clinical Documentation Specialist (CDS) II is a more experienced CDS spending at least 75% of their time on independent reviews without supervision creating queries and facilitating their follow-up. Level 2 specialists create trend reports to provide insights into documentation practices and engage directly with physicians to manage queries. They spend 25% of their time mentoring the CDS I and providing feedback to leadership.
Principal Responsibilities:
Reviews and analyzes clinical information with the electronic health record to identify areas within the chart for potential gaps in physician/provider documentation.
Formulate credible clinical documentation clarifications to improve clinical documentation of principal diagnosis co-morbidities present on admission (POA) quality core measures and patient safety indicators (PSI).
Confirms and/or assigns a working diagnostic related group (DRG) and severity level using coding rules and guidelines with follow up reviews as required by length of stay (LOS) standards.
Extracts essential data elements for reporting and tracking specifically for Joint Commission record reviews CORE measures severity of illness (SOI)/risk of mortality (ROM) assessments patient safety indicators (PSI) and revenue optimization criteria dedicating full attention to core measure responsibilities.
Engages in ongoing queries with physicians and providers to clarify and enhance documentation specificity in medical records.
Conducts post discharge reviews for comparative analysis clinical documentation integrity (CDI) and Coding assigned codes.
Communicates with physicians nurse practitioners case managers coders and other members of the care team to facilitate comprehensive medical record documentation to reflect treatment decision-making and medical documentation.
Identifies trends related to documentation issues provider specific concerns code specific needs etc.
Makes presentations to peer audiences on various topics such as clinical diagnoses regulatory changes guidelines new practices etc.
Mentors and precepts Clinical Documentation Specialist Level 1. Initiates special clinical documentation integrity (CDI) projects for process improvement.
Department Specific Responsibilities:
Teamwork/Customer Relations Responsibilities:
Collaborates to problem solve and make decisions to achieve desired outcomes
Establishes effective working relationships with cross-functional team(s)
Responds timely effectively and appropriately to deliverables
Shares knowledge time and expertise to assist other members of the team
Cultivates and maintains strong customer relationships and rapport with stakeholders and/or client groups
Ensures practices and procedures are inclusive of interpersonal and cultural diversity
Identifies and responds appropriately to both internal and external customer needs utilizing available resources
Represents the company with external constituents
Qualifications
Qualifications:
Education:
High school diploma or GED required
Bachelors Degree in Nursing or other advanced health care field preferred
Foreign trained MDs will be considered
License/Certifications:
Registered Nurse LVN Occupational Therapist Physical Therapist Physician Assistant foreign MD license or certification in Health Information Management or Medical Coding such as RHIT RHIA CDIP OR CPC preferred
CCDS required
Experience:
A minimum of 3 years of experience in Acute Clinical Care Utilization Review Coding or Case Management preferred
Working knowledge of Joint Commission standards and regulatory requirements
2 years performing CDI reviews within an acute care facility or bedside experience required
Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes preferred
Solid computer proficiency required
Minimum Salary
51.50
Maximum Salary
82.40
Required Experience:
IC
About Company
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