Prime Healthcare

Clinical Documentation Specialist Coordinator Trainee

Facility Paradise Valley Hospital
Location
US-CA-National City
ID
2022-90731
Category
Business Professional
Position Type
Full Time
Shift
Days
Job Type
Non-Exempt

Overview

Join an award-winning team of dedicated professionals committed to our core values of quality, compassion and community! Paradise Valley Hospital, a member of Prime Healthcare, offers incredible opportunities to expand your horizons and be part of a community dedicated to making a difference.

Paradise Valley Hospital is the South Bay’s oldest hospital, the second oldest hospital in all of San Diego County, and the largest employer in National City. For more than 100 years, Paradise Valley Hospital has served San Diego faithfully, proud of our heritage and providing numerous programs and services to meet the changing needs of our community. Our 291-bed, acute care hospital features the San Diego Spine & Joint Center, a highly credentialed acute rehabilitation center, our Paradise Health & Senior Center, a fully equipped and modern cardiac catheterization lab, and comprehensive inpatient and outpatient surgical services, and 24-hour emergency services.

In addition to our healthcare services, we offer comprehensive behavioral health services on the hospital campus and Bayview campus in Chula Vista. Services include psychiatric continuum of care for adult patients, inpatient services, and intensive outpatient services. Learn more at https://www.paradisevalleyhospital.net/.

Responsibilities

  • Reviews inpatient medical records for identified payor populations (i.e., Medicare, etc.) as directed on admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.
  • Ensures that clinical documentation reflects the level of service rendered to patients is complete, accurate and compliant with the regulations of the Center for Medicare and Medicaid Services.
  • Utilizes both clinical and coding knowledge to obtain appropriate documentation through extensive interaction with physicians, nursing, other patient caregivers and Health Information Management staff
  • Performs initial inpatient charts reviews for documentation of inpatient admission criteria and assign working DRG within 24 hours of admission, on the working days.
  • Assist CDS to Manages the concurrent medical record review for clinical documentation improvement throughout the hospital. Identifies physician documentation issues/omissions/discrepancies and assists physicians with improving documentation in the medical record.
  • Regularly participates in scheduled case management and hospitalist meetings and actively exchanges information pertaining to clinical documentation, plan of care affecting coding and reimbursement.
  • Maintains up to date working DRG to effectuate improved quality of clinical documentation for all the select cases under CDS supervision.
  • Assists in the development of diagnosis/DRG specific queries to aid physicians with proper and precise documentation.
  • Assist CDS and CDS manager to facilitates the appropriate clinical documentation to ensure that the intensity of services and level of acuity of the patient is accurately reflected in the medical record. Ensures abnormal findings are addressed, and the patient’s past medical history of conditions is appropriately documented
  • Assists CDS in DRG assignment mismatch report of differences in DRG assignment by CDS and coders and provides feedback to supervising the Manager or Director for performance evaluation of CDI process.

Qualifications

 

EDUCATION, EXPERIENCE, TRAINING

 

Required qualifications:
1. Medical Graduate, PA or Nursing Graduate.
2. Minimum of 3 years clinical experience in an acute care setting.
3. Knowledge of care delivery documentation systems and related medical record documents.
4. Knowledge of age-specific needs and the elements of disease processes and related procedures.
5. Strong broad-based clinical knowledge and understanding of pathology / physiology of disease processes.
6. Excellent written and verbal communication skills. Excellent critical thinking skills.
7. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff and hospital management staff.
8. Working knowledge of inpatient admission criteria.
9. Ability to work independently in a time-oriented environment.
10. Computer literacy and familiarity with the operation of basic office equipment.
11. Assertive personality traits to facilitate ongoing physician communication.

 

 

We are an Equal Opportunity/Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources. EEO is the Law:https://www.eeoc.gov/sites/default/files/migrated_files/employers/poster_screen_reader_optimized.pdf

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