The Senior 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. He/ She functions at a higher level, with a focus on physician and clinical staff documentation education. Essential Duties:Directs and Educates Physicians/ Resi... more details
The Senior 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. He/She functions at a higher level, with a focus on physician and clinical staff documentation education.
Essential Duties:
- Directs and Educates Physicians/Residents and clinical staff on CDI process/goals, and will be held accountable to work in a collegial manner with physicians, staff and consultants.
- Leads and monitors the day-to-day operations of the Clinical Documentation Improvement responsibilities.
- Conducts reviews within 2 working days.
- Conducts follow up reviews of at least every three working days.
- Achieves a physician response rate of 50% through the education of physicians to the importance of the DRG Assurance Program, identifying non-responders and intervening as necessary.
- Will review surgical cases which yield a complication and co-morbidity capture rate of at least 70%.
- Will review medical cases which yield a complication and co-morbidity capture rate of at least 80%.
- Completes data entry worksheets and submits to HIM Supervisor/Tech for timely data entry.
- Identifies opportunities for improved documentation and queries physicians.
- Utilizes DRG track reports weekly and uses 3M Clintrac reports to evaluate performance.
- Identifies Medicare admissions using census report.
- Documents pertinent clinical findings signs/symptoms, assessments, consults, vital signs, medications, procedures, treatments, and diagnostics, consults with Coding Manager/Supervisor to assure proper and appropriate documentation when necessary.
- Identifies DRG assignments using the Ingenix DRG Expert.
- Attends meetings with Coders and identifies process improvement and educational opportunities.
- Assists Manager with accomplishment of department goals with other duties as assigned.
- Utilizes monitoring tools to track the progress of the DRG Assurance Program through interpretation of DRG Track reports.
- Reviews 85% of Medicare admissions after implementation complete.
- 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.
- 3 years Clinical experience in an acute care setting.
- Knowledge of 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:
- Registered Nurse - RN (CA Board of Registered Nursing) OR Foreign Medical Graduate.
- Certified Coding Specialist - CCS (AHIMA) OR ACDIS certification. If no card upon hire, one must be obtained within one (1)year of hire.
- 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)
The hourly rate range for this position is $53.00 - $87.45. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.
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.
Read USC’s Clery Act Annual Security Report
Notice on Non-Discrimination
Certain positions are subject to background screening
EEO is the Law
EEO is the Law Supplement
Pay Transparency Non-Discrimination
USC is an E-Verify Employer
If you are a current USC employee, please apply to this USC job posting in Workday by copying and pasting this link into your browser:
https://wd5.myworkday.com/usc/d/inst/1$9925/9925$100409.htmld