Job Abstract

The Clinical Documentation Specialist (CDS) provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation of acute care services. Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Improves the overall quality and completeness of clinical documentation by working closely with providers and the application of coding guidelines, evidence-based knowledge, analysis, in-depth review, interpretation, identification of opportunities, communication, and consistent follow-up and evaluation of concurrent and retrospective (as required) medical record documentation.

Essential Duties:

• Identifies his/her respective service line(s) admissions in the CDI software/tool; and prioritizes reviews by age and payer. Completes his/her assignments by the end of the day
• Conducts new inpatient admissions reviews and proper working DRG assignment within 2 working days.
• Conducts follow up reviews and respective working DRG updates at least every 2 working days.
• Achieves a physician response rate of 100% through CDI education and interaction with physicians, identifying non-responders and intervening as necessary. Follows the query escalation process when no response.
• Identifies opportunities to improve documentation through physician query generation. Practice the mnemonic ‘MEAT’ (Monitored, Evaluated, Assessed or Treated) for building compliant and non-leading CDI queries. Applies evidence-based clinical criteria for clinical validation of diagnoses
• Utilizes the CDI software properly for tracking of CDI metrics and to assure compliance: documentation of pertinent clinical findings, compliant/non-leading queries, completion of all the required fields for data integrity and professional communication with coders and other staff members
• Directs a proper and complete CDI-Coding reconciliation process to accurate capture the complexity of the patients. Performs retrospective reviews and queries when necessary.
• Performs other related duties as assigned.

Required Qualifications:

• High school or equivalent
• Specialized/technical training Graduate of an accredited school of registered nursing and/or foreign medical graduate.

• 2 years Clinical documentation improvement experience.
• 3 years Clinical experience in an acute care setting.

• Demonstrates knowledge of ICD10-CM & PCS with respective coding guidelines & regulations for coding and reporting.
• Proficient on Inpatient Prospective Payment System (IPPS) documentation requirements for proper APR and MS DRGs assignment.
• Care delivery documentation systems and related medical record documentation.
• Strong broad based clinical knowledge and understanding of pathology/physiology of disease processes.
• Excellent written and verbal communication skills.
• Excellent critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurses, and hospital staff.
• Working knowledge of inpatient admission criteria.
• Ability to work independently in a time oriented environment.

Preferred Qualifications:

• Working knowledge of Medicare reimbursement system and coding structures.

Required Licenses/Certifications:

• Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)
• Registered Nurse - RN (CA Board of Registered Nursing) OR Foreign Medical Graduate. (or valid state of residence Registered Nurse license for out-of-state employees [working remotely])
• Certification - Job Relevant Certified Clinical Documentation Specialist (CCDS); OR Certified Documentation Improvement Practitioner (CDIP)

USC is an equal opportunity, affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, disability, or any other characteristic protected by law or USC policy. USC will consider for employment all qualified applicants with criminal histories in a manner consistent with the requirements of the Los Angeles Fair Chance Initiative for Hiring ordinance. We provide reasonable accommodations to applicants and employees with disabilities. Applicants with questions about access or requiring a reasonable accommodation for any part of the application or hiring process should contact USC Human Resources by phone at (213) 821-8100, or by email at uschr@usc.edu.  Inquiries will be treated as confidential to the extent permitted by law.

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