CDI Specialist - Health Information Management

12 month contract- REMOTE- W2 contractors only- MUST BE A LICENSED CALIFORNIA RN

  • Los Angeles, CA
  • $45 - $53
  • Hourly
  • Managed by Jobot Pro: Rey Robles
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A bit about us:

At our organization, you can turn great aspirations into great outcomes—for our patients and yourself. You’ll be challenged and empowered in an atmosphere of learning and support, working alongside world-class colleagues as you contribute to our reputation as an internationally-respected healthcare leader. Every day, you’ll be able to make a significant difference for our patients, our community and your team members.

No matter where you work within our system, you’ll experience an incomparable variety of lifestyle options. From the city to the suburbs, beaches to the mountains, and everything in-between, you’ll discover an incredible diversity of locations offering unmatched choices for world-renowned culture, recreation, dining, shopping, schools and so much more.

Why join us?

12 Month contract with a prestigious health system., Great Benefits offered through Jobot for this contract engagement.

Job Details

Clinical Documentation Specialists are responsible and accountable for the day-to-day management and success of the Continuous Documentation Improvement Project to include all modalities, acting as a liaison with specific department staff, speaking, meeting and educating physicians, residents and mid-levels, and assisting with the development and implementation of clinical documentation improvement processes. CDSs work in conjunction with Medical Coding, Case Management and other health team members to gather and analyze information in order to provide for comprehensive medical record documentation that accurately reflects clinical treatment, decisions, and diagnosis for inpatients. The Clinical Documentation Specialist utilizes clinical expertise and some coding knowledge to identify opportunities and ensure accuracy and completeness of clinical documentation used for measuring and reporting physician and hospital outcomes, including quality measures. Physician queries are generated to assist and improve the quality of the documentation. CDSs also supply support to the Medical Coders, Quality staff and revenue cycle team in the complaint coding and processing of inpatient claims.

  • Completes review of medical record for identified patients in the required timeframes.
  • Identifies and creates documentation queries to be sent to physicians, residents and mid-levels.
  • Communicates with physicians face to face or via CDI query forms to clarify information, obtain needed documentation and educate for appropriate DRG based on severity of illness and risk of mortality.
  • Follows up on all queries sent and maintains timely review of medical records while patient remains an inpatient.
  • Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, and impact of procedures on DRG; and is able to impart this knowledge to physicians, residents, mid-levels, nurses and other health team members.

  • Applies appropriate documentation to a computer database (EPIC/Care Connect and 3M 360 Encompass) to identify the most appropriate diagnosis and CC’s to accurately reflect the severity of illness.
  • Confers with physicians, residents, nurses and other clinical caregivers to explain the importance of clear and concise documentation.
  • Continuously confers with hospital coding staff to ensure appropriate DRG and completeness of supporting documentation.
  • Collaborates with coders to ensure AR days remain in target range
  • Reviews records upon coding request to confirm DRG assignment or need to follow up with physician regarding incomplete documentation

  • Continually assesses and improves physician, case manager, nurse and other education for the health team to promote complete and accurate clinical documentation and correct negative trends.
  • Conducts seminars and presentations to hospital staff, as needed, to educate on specific departmental and hospital-wide topics related to clinical documentation and quality.

  • California Registered Nurse (or equivalent)
  • Minimum of three years of clinical hospital experience; or equivalent of education and experience in case management, utilization management or prior clinical documentation review experience
  • Recent experience in care management, quality utilization or coding
  • Working knowledge of laws, rules and regulations regarding appropriate clinical documentation for government programs as Medicare and MediCal.
  • Leadership, supervisory, and training skills.
  • Self-directed, assertive and excellent critical thinking skills, knowledge of documentation systems and related medical record documents.
  • Demonstrates resourcefulness, effective written and oral communication, diplomacy, organizational, and analytical skills.
  • Ability to work effectively and collaboratively with physician/staff and interdisciplinary teams.
  • Basic working knowledge of a large University teaching hospital; its purpose and functions.
  • Basic computer skills.
  • Ability to effectively communicate to physician/staff the necessity/appropriateness of clinical documentation
  • Ability to effectively communicate to the payer the medical necessity/appropriateness /level of care criteria that is necessary for acute care hospitalization.
  • Skills in setting priorities that accurately reflect the relative importance of job responsibilities.
  • Skill in abstracting and interpreting medical information from patient records.
  • Working knowledge of laws, rules, and regulations regarding utilization review and discharge planning functions of government programs such Medicare, Medi-Cal, and CCS.
  • Clinical experience sufficient to understand and communicate medical diagnosis and courses of treatment to professional and non-professional personnel.
  • Immediate knowledge of computer word processing, database programs and ability to write reports and do graphical analysis.

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Job Details
Managed by Jobot Pro
Los Angeles, CA
Job Type
$45 - $53