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LEAD CLINICAL DOCUMENTATION SPECIALIST: FULL-TIME***INTERNAL ONLY***

Job ID 7528-977 Date posted 04/30/2019

We’re a nonprofit, regional healthcare network with two hospitals, numerous outpatient medical offices, a multi-specialty medical (physician) group, home healthcare services and hospice care, as well as heart, cancer and emergency services. Our leadership is dedicated to putting patients first—a cornerstone of our mission, vision and values—as we deliver top-quality healthcare.

From our extensive facilities in Whittier, California and Downey, California, PIH Health serves more than two million residents in Los Angeles and Orange Counties and throughout the San Gabriel Valley.

The Clinical Documentation Improvement Specialist Lead will be responsible for facilitating clinically appropriate documentation of all patient conditions, treatments, and interventions to accurately reflect the reason for admission, conditions present on admission, quality of care, severity of illness, and risk of mortality to support correct coding, reimbursement and quality initiatives.Lead is responsible for providing training to CDI staff, holding staff accountable for meeting productivity standards, and for completing daily, weekly, and monthly assignments. Lead is also responsible for conducting regular concurrent and retrospective audits of patient accounts worked by each staff member to ensure compliance with quality standards and regulatory requirements. Lead will communicate regularly with the Physician Advisor, HIM Director, and/or Vice President of Revenue Cycle, escalating issues immediately as they are discovered following the appropriate chain of command.


Required Skills

  • Clinical experience with an Acute Care Inpatient background in Critical Care or Emergency Department
  • Experience with criteria-based chart review, such as Case Management, Utilization management, Managed Care, Quality Improvement
  • Knowledge of ICD-10, the MS-DRG structure, HAC’s, PSI’s, value based purchasing, bundled payments, accountable care organizations and readmission reduction programs.
  • Ability to reference and interpret CMS guidelines and regulatory requirements
  • Must work independently in performing duties with minimal supervision with a high degree of self-motivation                                       
  • Critical thinking, creative problem solving and conflict management skills
  • Extensive knowledge of pharmacology and pathophysiology and disease processes
  • Computer savvy: Microsoft Office/Suite proficient
  • Excellent verbal communication skills for face to face interactions with physicians, to foster relationships of clinical skills and information sharing
  • Ability to write queries that are concise and easily understood by the provider in order to garner additional/clarification of documentation
  • Ability to develop and maintain supportive, collaborative relationships with physicians and other clinical professionals
  • Strong attention to detail: highly organized

Required Experience

  • Minimum Qualifications: Graduation from accredited School in nursing with BSN and current licensure as a RN in the State of California, or International Physician Medical graduate.
  • A minimum of 3-5 years’ experience in Critical Care or Emergency Department nursing or physician clinical experience.
  • Familiarity with ICD-10 and knowledge of the AHA Coding Clinic preferred
  • CCS, CCDS, or CDIP combined with hospital-based clinical experience preferred
  • Minimum 1 year of experience working as a CDS within a hospital environment; leadership or supervisory experience preferred

Beyond the benefits that come with working for the area's leading community healthcare provider – one that also recognizes the need to ensure patient safety and comfort – you'll enjoy an extremely competitive compensation and benefits package.  We are an equal opportunity employer and seek diversity in our workforce.   EOE M/F/D/V

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