Clinical Documentation Specialist
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Job Description
Clinical Documentation Specialist enhancing documentation quality for patient care at City of Hope. Collaborating with healthcare professionals to optimize reimbursement and improve clinical outcomes.
Responsibilities:
- Facilitate improvements in clinical documentation quality, completeness, and accuracy to support patient care and reimbursement outcomes.
- Analyze clinical records and identify documentation opportunities related to severity of illness, risk of mortality, and coding accuracy.
- Assign working DRGs for inpatient admissions and support appropriate code assignment.
- Collaborate with physicians, Nurse Case Managers, and multidisciplinary care teams to obtain complete and accurate clinical documentation.
- Query providers to clarify incomplete, conflicting, or ambiguous documentation using approved processes.
- Perform clinical record abstracting and data collection to support reimbursement, quality initiatives, and outcome reporting.
- Educate physicians and care teams on documentation standards, coding updates, MS-DRG changes, and coding guidelines.
- Ensure the accuracy and integrity of medical record data prior to billing and claims submission.
- Partner with Patient Accounting and coding teams to resolve reimbursement and documentation-related issues.
- Support quality management and continuous improvement initiatives through data analysis, education, and documentation integrity efforts.
Requirements:
- Associate’s or Bachelor’s degree in Health Information Management and/or a Certified Coding Specialist (CCS) credential.
- Minimum of two years of inpatient clinical coding experience or successful completion of a coding competency assessment.
- CCS, CDIP, or CCDS certification required.
- Familiarity with concurrent coding models strongly preferred.
- Proficiency with Encoder/Grouper technology and strong computer skills.
- Understanding of clinical documentation improvement (CDI) principles and coding compliance requirements.
- Ability to effectively communicate and collaborate with physicians and interdisciplinary teams.
- Strong analytical, critical thinking, and problem-solving skills.
- Commitment to maintaining data integrity, coding accuracy, and regulatory compliance.
- Nursing degree and/or registered nurse experience preferred.
Benefits:
- Comprehensive Benefits
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