What are the responsibilities and job description for the Clinical Documentation Integrity Specialist - Clinic Outpatient position at Adventist Health?
Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.
Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.
Job Summary:
Reviews, evaluates and assesses medical records of patients, looks for specificity of an illness, the accuracy of the clinician's documentation, coding requirements and documentation of important medical details to ensure the overall quality and completeness of clinical documentation of the patient medical record and ensure it is in compliance with government and other regulations. Works on problems of moderate to diverse scope requiring some interpretation of policies and guidelines. Applies working knowledge of the techniques, principles, theories and concepts to complete routine and non-routine assignments. Runs program(s) with moderate budget/impact.
Job Requirements:
Education and Work Experience:
- Associate's Degree or equivalent combination of education/related experience: Preferred
- Two years' clinical, or coding experience: Required
- Registered Health Information Administrator (RHIA)/Registered Health Information Technician (RHIT) with Certified Coding Specialist - Professional (CCS-P) or Certified Professional Coder (CPC) and relevant clinical background/ experience: Preferred
- 2 years' of outpatient clinic audit experience.: Required
- One year of leadership experience.: Required
Licenses/Certifications:
- Certified Clinical Documentation Specialist (CCDS) issued by the Association of Clinical Documentation Improvement Specialists (ACDIS) OR Certified Documentation Improvement Practitioner (DIP) issued by the American Health Information Management Association (AHIMA): Preferred
- Current licensed RN, medical provider or equivalent: Preferred
Essential Functions:
- Evaluates and assesses medical records of patients, looks for specificity of an illness, the accuracy of the clinician's documentation, coding requirements and documentation of important medical details to ensure the overall quality and completeness of clinical documentation of the patient medical record.
- Analyzes and interprets medical records and clinical documentation and formulates appropriate physician queries.
- Provides training for providers, CDS' and coders as necessary
- Keeps abreast of regulatory changes related to documentation, coding and communicate these changes to appropriate staff. Follows documentation guidelines and legal requirements to ensure compliance with federal and state regulatory bodies.
- Acts as a liaison between the medical staff and the coding department. Works collaboratively with physicians and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate clinical diagnosis and level of severity is captured for the level of service rendered to all patients.
- Performs other job-related duties as assigned.
Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.
The estimated base pay for this position is $64.72 to $88.77. Additional individual compensation may be available for this role through years of experience, differentials, extra shift incentives, bonuses, etc. Base pay is only a portion of the total rewards package, and a comprehensive benefits program is available for qualifying positions. Please contact our Talent Acquisition team for more information
Salary : $65 - $89
