Job Description

Job Description

Immediate need for a talented Clinical Documentation Specialist CDI in California. This is a 06+months contract opportunity with long-term potential and is located in California (REMOTE ). Please review the job description below and contact me ASAP if you are interested.

Job ID: 25-77657

Pay Range: $45 - $50/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Key Responsibilities:

• Effective and efficient inpatient concurrent medical record review for accurate and complete documentation, within an electronic medical record environment.
• Reviews clinical cases in collaboration with medical coding staff and physicians, to identify additional diagnoses that impact severity of illness/risk of mortality indicators for each patient.
• Manages and prioritizes numerous cases on a daily basis.
• Manages cases at the facility level, using flexibility to provide coverage for any NCAL facility, based on staffing need, as determined by census, on a daily basis.
• Facilitates appropriate clinical documentation to support diagnosis capture and to ensure the level of service rendered to all patients is accurately recorded and reflected.
• Provides expert analysis of the medical record documentation for signs/symptoms/clinical indicators, to identify potential primary and secondary diagnoses and complications existing within each patient case.
• Formulates and distributes physician documentation clarification queries following coding guidelines and all applicable compliance standards.
• Creates, monitors and tracks verbal and written queries, responses and their impact; producing reports as required.
• Identifies documentation trends, and areas of opportunity for physician education regarding documentation.
• Conducts data and root cause analysis, provides feedback and shares findings on the analysis to regional CDI Leadership.
• Collaborates with TPMG contacts and CDI staff and Leadership in the development of programs which provide alignment with education for internal customers to support clinical documentation guidelines.
• Leads special projects/committees that contribute to the development of an effective CDI program. Collaborates and communicates with local HIM staff and local HIM leadership to ensure accurate documentation capture.
• Effectively communicates with local coding staff regarding query responses, to assist with the efficiency and completeness of the medical record of the post-discharge physician query process.
• Provides feedback and serves as clinical expert resource to CDIC QA staff.
• Provides expert advice to CDI Regional Managers to develop, implement and monitor policies and procedures that support organizational goals and business objectives related to the CDI Program.
• Adheres to organizational standards to promote a cooperative work environment by utilizing professional communication skills.
• Collaborates effectively with coding professionals, nursing and clinical experts, ancillary services, physicians and administration.
• Establishes, fosters and maintains effective working relationships with the local and regional staff/teams/leadership.
• Client’s conducts compensation reviews of positions on a routine basis.
• At any time, Client’s reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status.
• Such changes are generally implemented only after notice is given to affected employees

Key Requirements and Technology Experience:

• Key Skills; CCDS, CCS, CDIP
• A minimum of 3–5 years of recent experience in Clinical Documentation Improvement (CDI) is required.
• Candidates must hold at least one of the following certifications: CCDS (Certified Clinical Documentation Specialist), CDIP (Clinical Documentation Improvement Practitioner), or CCS (Certified Coding Specialist) or any other Certificate.
• Educational background should include one of the following: Nursing (BSN or MSN), MD, Foreign Medical Graduate, or an allied health degree.
• CCS, CCDS or CDIP Certification
• Clinical Documentation Improvement.

Our client is a leading Healthcare Industry, and we are currently interviewing to fill this and other similar contract positions. If you are interested in this position, please apply online for immediate consideration.

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