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Clinical Document Improvement Specialist

Company: Kern Medical
Location: Bakersfield
Posted on: August 16, 2019

Job Description:

Kern Medical has been a community cornerstone since its founding in 1867. Today, we are an acute care teaching center with 222 beds, offering the only advanced trauma care between Fresno and Los Angeles. Kern Medical offers a range of primary, specialty, and multi-specialty services including high-risk pregnancy care, inpatient psychiatric services integrated with county mental health programs, and a growing network of outpatient clinics providing personalized patient-centered wellness care. Kern Medical cares for 15,500 inpatients and 125,000 clinic patients a year. Career Opportunities within Kern Medical include many benefits such as:

  • New Hire Bonus: $6,000.00
  • New Hire Premium: +6% of base rate of pay, matched up to 6% if contributed to Deferred Compensation Plan.
  • Shift Differential Pay: P.M. shift (7:00 PM - 7:30 AM) = 10% of base pay.
  • A Comprehensive Benefits Package: includes Holidays, Paid Time Off, Retirement, Medical, Dental, Vision and Life Insurance. Position: Clinical Document Improvement Specialist - RN DISTINGUISHING CHARACTERISTICS: The Clinical Documentation Improvement Specialist is a single position classification responsible for educating members of the patient care team regarding documentation guidelines, including attending physicians, residents, allied health practitioners, nursing, and case management. This position will also work closely with the HIS Department Coders and other medical staff as deemed necessary. Essential Functions
    • Completes initial reviews of patient records within twenty four (24) hours of admission for a specified patient population (IPT) to: (a) evaluate documentation to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate DRG assignment, risk of mortality, and severity of illness; and (b) initiate a review worksheet.
    • Conducts follow-up reviews of patients every two to three days to support and assign a working or final DRG assignment upon patient discharge, as necessary.
    • Queries physicians regarding missing, unclear, or conflicting health record documentation by requesting and obtaining additional documentation within the health record when needed before patient is discharged.
    • Educates physicians and key healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the health record.
    • Collaborates with case managers, nursing staff, and other ancillary staff regarding interaction with physicians on documentation and to resolve physician queries prior to patient discharge.
    • Participates in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.
    • Assists with preparation and presentation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership at Medical Records Committee, UR Committee. OTHER FUNCTIONS:
      • Performs other related duties as required. Employment Standards Current California license as a Registered Nurse and two (2) years of experience in nursing or other clinical area utilizing coding, process improvement, or utilization review/case management in an acute care facility. Employees must maintain all health requirements designated by Kern Medical.Knowledge of: health care delivery systems; health information (medical records) for inpatient and outpatient facilities; federal and state laws and legislative developments governing medical records to ensure compliance; the International classification do Diseases Clinical Modification System; current version of CPT Codes; and, Diagnostic Related Group coding applications.

Keywords: Kern Medical, Bakersfield , Clinical Document Improvement Specialist, Healthcare , Bakersfield, California

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