Clinical Document Improvement Specialist
Company: Kern Medical
Posted on: August 16, 2019
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
- 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.
- 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
- 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
- Participates in the analysis and trending of statistical data
for specified patient populations to identify opportunities for
- 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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