Job Abstract

Job Summary

Performs concurrent reviews of medical records checking for accurate documentation. The reviews include new admissions as well as subsequent reviews every one to two days of the chart on patients previously reviewed and remaining in-house until discharge. Will assist CDI Supervisor with data analysis and report generation, presentations, training and orientation functions.

Licensure and Certification:

• Active CCS certification or
• Active CCDS certification or Active CDIP or
• Medical doctor license outside/inside the U.S. or
• Active Physician Assistant (PA) License or
• Active RN license in the state of California

Education:

• AS or Bachelor’s degree in Health Information Management or
• BS Medicine or equivalent or
• BS Nursing

Experience:

• Acute hospital experience, with three (3) years of inpatient and outpatient coding experience utilizing an encoder required or
• Acute hospital experience, with three (3) years of CDI or clinical experience required and five (5) years preferred

Knowledge and Skills:

• Documentation training in ICD-10
• Building and maintaining strategic working relationships
• Building trust
• Organization and initiative
• Communication and interpersonal skills
• Teamwork
• Adaptability
• Customer service
• Proficient clinical assessment skills
• Thorough understanding of coding guidelines and physician documentation impact
• Working knowledge of MS-DRG, and APR-DRG

Physical Demands – Clerical/Administrative Non-Patient Care:

• Frequent sitting and standing/walking with frequent position change.
• Continuous use of bilateral upper extremities in fine motor activities requiring fingering, grasping, and forward reaching between waist and chest level.
• Occasional/intermittent reaching at or above shoulder level.
• Occasional/intermittent bending, squatting, kneeling, pushing/pulling, twisting, and climbing.
• Occasional/intermittent lifting and carrying objects/equipment weighing up to 25 pounds.
• Continuous use of near vision, hearing and verbal communication skills in handling telephone calls, interacting with customers and co-workers and performing job duties.