Clinical Documentation Improvement Specialist - RUHS

Riverside University Health System-Medical Center has several opportunities for Clinical Documentation Improvement Specialists.  These positions have either a Monday-Friday or a Tuesday - Saturday, 9/80 work schedule, and offer a hybrid remote schedule, one day per week in the office (during training more time in the office may be required).   

About the different roles:
Incumbents will be involved in the secondary review process along with the Quality team and Providers.  

• The primary review process includes CDI standard workflow and query to the primary provider to validate/reconcile documentation; 
• The secondary review process entails the review of more complex cases, or in cases when a response was not provided during the initial CDI query.  
• This team's participants include representation from CDI, Quality/Patient Safety and Providers (champions and primaries).

Incumbents will prioritize the review of the following for Quality :

• Patient Safety Inquiries
• Hospital Acquired conditions
• Readmissions

Ideal candidates will have significant RN experience and education or significant professional coding and abstracting experience in an acute care hospital, along with applicable certification(s), AND experience utilizing EPIC and 3M Clinical Documentation Integrity Services.  

Meet the Team!
Riverside University Health System-Medical Center consistently receives national recognition for its progressive and innovative care, as well as being known as one of the top employers in the region.  The 439-bed Medical Center is a designated Stroke Center, Level II Trauma Center, and the only Pediatric ICU in the region. Can you see yourself here? For more information on RUHS-Medical Center, please visit www.ruhealth.org 




• Complete admission reviews of patients' records within 24-hours of admission to evaluate and analyze documentation in order to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate and optimal CMS-Diagnostic Related Group (CMS-DRG) assignment.

• Initiate and perform concurrent documentation reviews of selected inpatient and outpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists, and conduct follow-up reviews as necessary.

• Develop and implement methods of improving the clarity, accuracy, and completeness of clinical documentation; monitor and evaluate coding outcomes and provide periodic status to medical center departments and committees.

• Communicate with and serve as a resource for physicians, nurses, and other healthcare providers to facilitate complete and accurate documentation of the patient record; query physicians regarding missing, unclear, or conflicting medical record documentation and obtain additional documentation; keep physician leaders informed of pertinent data, documentation trends, and opportunities for learning and improvement related to documentation integrity.

• Code a wide variety of procedures and primary and secondary diagnoses according to the applicable International Classification of Diseases (i.e., ICD-10-CM or subsequent adaptation) coding system and CPT-4 procedural coding system; prepare pertinent data from medical charts according to criteria established by the Office of State Wide Hospital Planning and Development (OSHPD) and the Medical Audit Committee or individual physicians for various studies, statistical indexing, and preparation of summary reports to various regulatory agencies.

• Collect data for performance improvement and report findings and outcomes; participate in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.

• Participate in revenue cycle meetings, providing data relative to reimbursement concerns; educate physicians and healthcare providers regarding documentation matters related to coding, billing, and reimbursements.OPTION I

Education: Graduation from an accredited college or university with a Bachelor's degree in nursing.

Experience: Three years of Registered Nurse experience in an acute care hospital.

License/Certificate: Must possess and maintain a current valid license to practice as a Registered Nurse in the State of California.

Possession of valid Basic Life Support (BLS) Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) certificates issued by the American Heart Association for professional healthcare providers.

OPTION II

Education: Graduation from an accredited college or university with a Bachelor's degree in Health Information Management or Health Information Technology.

Experience: Four years of professional coding and abstracting medical records in an acute care hospital.

Certificate: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician, or Registered Health Information Administrator issued by the American Health Information Management Association.

OPTION III

Education: Completion of Doctor of Medicine degree.

Experience: One year of clinical documentation improvement experience in a healthcare setting.

Certificate: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician, or Registered Health Information Administrator issued by the American Health Information Management Association. Certification in Clinical Documentation preferred.

Knowledge of: Coding, abstracting, and terminology systems such as: International Classification of Diseases, Clinically Modified (ICD-10), and Current Procedural Terminology (CPT- 4); comprehensive medical terminology covering a wide variety of medical specialties; clinical documentation standards; federal, state, and local laws and regulations governing professional aspects of nursing; payor source documentation requirements and governmental regulations affecting reimbursement.

Ability to: Analyze and interpret the technical elements of a medical chart; analyze, code, and abstract complex technical data from medical records covering a wide variety of medical specialties utilizing an encoder and electronic abstracting system; prepare and maintain concise and complete records and reports; establish and maintain effective working relationships with physicians, patients and fellow employees; effective communication skills.What's Next?
Open to All Applicants.
This recruitment is open to all applicants. Applicants who are current employees of RUHS-Medical Center may be considered before other applicants depending on the volume of applications received.

Based on the number of applications received, this posting may close without notice, and applications will be reviewed and considered in the order in which they were received. 

For questions regarding this recruitment, please contact the recruiter Angela Levinson at 951-955-5562 or alevinson@rivco.org.

Salary : $96,139 - $130,293