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Cedars-Sinai Clinical Documentation Specialist (per diem) - Medical Management in Beverly Hills, California

Under the general direction of the HID CDI/Core Measures Supervisor, the Clinical Documentation Specialist has two primary areas of responsibility. Within the Clinical Documentation Integrity program (CDI), the CDS is responsible to assist physicians in improving the overall quality and completeness of clinical documentation. Within the CORE Measure/Regulatory Review program (CORE), the CDS is responsible for reviewing and assessing the clinical and non-clinical documentation for compliance with The Joint Commission (TJC), hospital and state/federal regulatory requirements.

Primary Duties and Responsibilities

  • Performs record review (quantitative and qualitative) and assesses the level of compliance with stated regulatory requirements by area of job focus.Assigns a working MS-DRG/APR-DRG or diagnosis specific review criteria for CORE measure decision trees within the set time frames.May also review inpatient and outpatient records as part of the hospital wide medical record review program for the Joint Commission.Captures and maintains the related review data in designated computer systems or databases.

  • Assists in clarifying clinical information used for measuring and reporting physician and medical center outcomes which incorporates current DRG methodologies (e.g. MS-DRGs, etc.) by CMS and/or other regulatory/quality reporting bodies (e.g. APR-DRGs, SOI, ROM, etc).Issues queries to members of the patient care team – primarily physicians – regarding possible diagnoses or to improve the specificity of diagnoses thru enhanced clinical documentation.Facilitates modifications to clinical documentation as needed to support component stated previously.

  • Leads or provides education/training to clinical care (physicians, nurses, etc.) and administrative support team members regarding the clinical documentation requirements essential for demonstrating quality patient care (SOI, ROM, etc.), the regulatory interpretation of outcomes for focused diagnoses, and their impact on reimbursement and quality reporting for the organization.Assists in developing educational materials as needed.

  • Demonstrates knowledge of applicable regulatory standards/requirements by applying them accurately when providing guidance to customers. Accurately applies knowledge during record review activities.

  • Supports ad-hoc reviews or data collection activities for focused or special research studies conducted within the organization.

Teamwork/Customer Relation Responsibilities

  • Establishes effective working relationships with cross-functional team(s)

Educational Requirements:

  • High School Diploma/GED required

  • Bachelor's Degree in Nursing or Health Information Management (Foreign medical degree may be considered) preferred

License/Certification/Registration Requirements:

  • Current RN license (not limited to State of California) or higher clinical degree (i.e. MD), or Registered Health Info Admin, or Registered Health Info Tech required.

  • Clinical Documentation Improvement Professional or or Certified Clinical Documentation Specialist preferred

Experience:

  • Three (3) years of acute care experience required.

  • Three (3) years of utilization review, coding, or case management experience preferred.

  • Analytical - Ability to apply critical thinking to analyze and interpret information and/or data. Strong critical thinking skills and ability to integrate knowledge.

  • Communication - Ability to convey and/or receive written/verbal information to/from various audiences in different formats. Excellent observation, communication and decision making abilities; Ability to strongly communicate and interact with all levels of professions, including but not limited to physicians and nursing personnel, managers, various support staff departments, physician offices, and coding, in a non-confrontational manner.

  • Communication - Ability to develop and deliver effective presentations.

  • Time Management - Ability to demonstrate time management and priority setting skills. Ability to prioritize work; Possesses a professional work ethic including meeting deadlines.

  • Technical\Ability to use software applications and operate technological devices (email, computer, etc.). Experience with 3M 360 Encompass modules, and EPIC EHR system preferred.

  • Regulatory - Ability to interpret and apply knowledge of State, Federal and Agency standards to comply with regulations.

Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law.

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