Clinical Documentation Specialist

    • Duarte, CA

About City of Hope
City of Hope, an innovative biomedical research, treatment and educational institution with over 6000 employees, is dedicated to the prevention and cure of cancer and other life-threatening diseases and guided by a compassionate, patient-centered philosophy.

Founded in 1913 and headquartered in Duarte, California, City of Hope is a remarkable non-profit institution, where compassion and advanced care go hand-in-hand with excellence in clinical and scientific research. City of Hope is a National Cancer Institute designated Comprehensive Cancer Center and a founding member of the National Comprehensive Cancer Network, an alliance of the nation’s leading cancer centers that develops and institutes standards of care for cancer treatment.

Position Summary:

As an essential member of the Coding and Data Quality team, the clinical documentation specialist is responsible for facilitating the improvement to the overall quality and completeness of clinical documentation. Seeks to obtain appropriate and accurate clinical documentation reflective of the severity of illness and risk of mortality. Ability to analyze clinical information and using critical thinking skills identify documentation opportunities. Assigns a working DRG for each inpatient admission for assigned population of patients. Interacts thoughtfully with physicians and other member of the patient care team to gather accurate and timely clinical information for abstraction into designated database. Queries physicians using the approved query process in order to obtain clinical information as identified. Provides ongoing education regarding documentation guidelines to members of the patient care team. Adheres to the standards of ethical coding and City of Hope policies and procedure.

Key Responsibilities include:

  • Assigns diagnoses and procedure codes to inpatient records based upon clinical record documentation and obtains a working DRG. Partners with Nurse Case Managers and physicians to identify opportunities for documentation improvement to support patient severity of illness and risk of mortality.
  • Query physician(s) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicator).
  • Performs clinical record abstracting and data collection to justify and support optimal reimbursement, data quality, performance improvement analysis, and outcome reporting initiatives. Assigns and sequences ICD-9 diagnosis and procedure codes in compliance with UHDDS, billing requirements, and organization specific policies.
  • Participates as an active member of the multi-disciplinary patient care team. In doing so, shares utilization metrics and acquires additional information about patient co-morbidities and complications. Works collaboratively with Nurse Case Managers during the patient’s episode of inpatient care to assist physicians and other practitioners to document diagnoses and procedures in a clear, concise, and comprehensive manner.
  • Utilizes electronic and hard copy resources available to ensure accuracy in assigning classification codes.
  • Assists with data collection and analysis to support quality management and continuous quality improvement efforts.
  • Informs and educates physicians and members of the multi-disciplinary care team of the coding changes, MS-DRG changes and or changes in coding guidelines as applicable.
  • Ensures accuracy and integrity of medical record abstract data during final discharge coding prior to billing interface and claims submission. Partners with Patient Accounting staff to resolve any issues related to coding / reimbursement.
  • Maintains documentation of physician queries / responses per established policies.
  • Educates and communicates to care team colleagues about clinical data integrity and utilization management including role responsibilities, tools, and resources.
  • Acquires and shares information about trends and issues in third party payer rules, regulations, and guidelines. Participates in Managed Care contracting activities as requested.
  • Performance Goals:
    • Meet established CDI initiatives
    • Maintain or improve physician and care team satisfaction with Clinical Documentation improvement activities.
    • Principal Diagnosis of symptom code will be reduced to less than 3% of total discharges.
    • Present on Admission indicator “U” will be clarified as “Y,” “N,” or “W”
    • Assists coding manager in identifying documentation opportunities for ICD-10-CM and ICD-10-PCS code set requirements.
  • Successful completion of required education courses.


Qualifications
Basic education, experience and skills required for consideration:
  • Associates and/or Bachelors degree in Health Information Management and /or a coding certification (CCS).
  • Two (2) years inpatient Clinical Coding experience required or completed competency assessment for inpatient coding at City of Hope. Familiarity with Concurrent Coding models highly desirable.
  • Proficiency with Encoder / Grouper technology and basic keyboarding skills.
Required Courses/Training :
  • Successful completion of required education courses.
Required Certification/Licensure:
  • CCS.

Additional Information:
  • This position is represented by a collective bargaining agreement.
  • 2 Openings.
City of Hope is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, sexual orientation, gender identity, age, status as a protected veteran, or status as a qualified individual with disability.


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