C
Clinical Documentation Specialist
Cedars-Sinai
10 hours ago
Full-time
On-site
Los Angeles, California, United States
Registered Nurse
The Clinical Documentation Specialist works independently and is responsible for
performing clinical chart
reviews and pre-charting on risk adjustable patient populations. The Clinical
Documentation Specialist
exercises critical thinking by applying clinical knowledge to correlate relevant
diagnoses for the primary
care physician (PCP) to consider at the time of the face to face visit. The
Clinical Documentation Specialist
will also be responsible for tracking and verifying all their findings.
Leads or provides education/training to clinical care and administrative support
team members regarding
the clinical documentation requirements essential for risk adjustable diagnoses
and their impact on
reimbursement and regulatory requirements set forth by CMS and other regulatory
entities. Assists in
developing educational materials as needed.
RESPONSIBILITIES
* Reviews and assesses medical charts clinically by suggesting risk adjustable
diagnoses to the PCP for
consideration in reflecting the true burden of illness.
* Supports a variety of projects as needed when reviewing related medical
records for Providers with high
volume or opportunity.
* Conducts pre-charting findings and orders prior to patient visit with PCP
daily/weekly.
* Reviews PCP’s documentation & coding to ensure documentation reflects the
true acuity of the patient.
Utilizes HCC analytics information to target populations for review based on
level of opportunity
* Updates OPA alerts with suspected HCC opportunities based on chart review
* Assisting in the development of HCC educational materials
* Provide direct elbow support to clinicians on documentation best practices
* Lead HCC educational sessions with new and returning physicians
QUALIFICATIONS
Education
* High School Diploma/GED - minimum
* Bachelor's Degree Bachelor's Degree in Nursing or Health Information
Management. - preferred
Experience
* 3 years Medicare risk adjustment coding & documentation required
* 2 years Experience providing training information to clinical and
administrative
staff preferred
* 3 years Experience using software such as Microsoft Office including Excel
and
PowerPoint to develop presentations preferred
* 1 year Exposure to risk adjustment analytics platform(s) to gain insights
into
risk adjustment performance and opportunities required
Licenses and Certifications
* Valid Clinical CA license preferred (PA, NP, LVN or RN)
* Registered Health Information Administrator preferred
* AHIMA or AAPC coding credential and/or registration (One or more of the
following: CDIP, CDEO, CCS, CPC, CRC) required
Cedars-Sinai is a leader in providing high-quality healthcare encompassing
primary care, specialized medicine and research. Since 1902, Cedars-Sinai has
evolved to meet the needs of one of the most diverse regions in the nation,
setting standards in quality and innovative patient care, research, teaching and
community service. Today, Cedars- Sinai is known for its national leadership in
transforming healthcare for the benefit of patients. Cedars-Sinai impacts the
future of healthcare by developing new approaches to treatment and educating
tomorrow's health professionals. Additionally, Cedars-Sinai demonstrates a
commitment to the community through programs that improve the health of its most
vulnerable residents.
With a growing number of primary urgent and specialty care locations across
Southern California, Cedars-Sinai’s medical network serves people near where
they live. Delivering coordinated, compassionate healthcare you can join our
network of clinicians and physicians to improve the healthcare people throughout
Los Angeles and beyond.
performing clinical chart
reviews and pre-charting on risk adjustable patient populations. The Clinical
Documentation Specialist
exercises critical thinking by applying clinical knowledge to correlate relevant
diagnoses for the primary
care physician (PCP) to consider at the time of the face to face visit. The
Clinical Documentation Specialist
will also be responsible for tracking and verifying all their findings.
Leads or provides education/training to clinical care and administrative support
team members regarding
the clinical documentation requirements essential for risk adjustable diagnoses
and their impact on
reimbursement and regulatory requirements set forth by CMS and other regulatory
entities. Assists in
developing educational materials as needed.
RESPONSIBILITIES
* Reviews and assesses medical charts clinically by suggesting risk adjustable
diagnoses to the PCP for
consideration in reflecting the true burden of illness.
* Supports a variety of projects as needed when reviewing related medical
records for Providers with high
volume or opportunity.
* Conducts pre-charting findings and orders prior to patient visit with PCP
daily/weekly.
* Reviews PCP’s documentation & coding to ensure documentation reflects the
true acuity of the patient.
Utilizes HCC analytics information to target populations for review based on
level of opportunity
* Updates OPA alerts with suspected HCC opportunities based on chart review
* Assisting in the development of HCC educational materials
* Provide direct elbow support to clinicians on documentation best practices
* Lead HCC educational sessions with new and returning physicians
QUALIFICATIONS
Education
* High School Diploma/GED - minimum
* Bachelor's Degree Bachelor's Degree in Nursing or Health Information
Management. - preferred
Experience
* 3 years Medicare risk adjustment coding & documentation required
* 2 years Experience providing training information to clinical and
administrative
staff preferred
* 3 years Experience using software such as Microsoft Office including Excel
and
PowerPoint to develop presentations preferred
* 1 year Exposure to risk adjustment analytics platform(s) to gain insights
into
risk adjustment performance and opportunities required
Licenses and Certifications
* Valid Clinical CA license preferred (PA, NP, LVN or RN)
* Registered Health Information Administrator preferred
* AHIMA or AAPC coding credential and/or registration (One or more of the
following: CDIP, CDEO, CCS, CPC, CRC) required
Cedars-Sinai is a leader in providing high-quality healthcare encompassing
primary care, specialized medicine and research. Since 1902, Cedars-Sinai has
evolved to meet the needs of one of the most diverse regions in the nation,
setting standards in quality and innovative patient care, research, teaching and
community service. Today, Cedars- Sinai is known for its national leadership in
transforming healthcare for the benefit of patients. Cedars-Sinai impacts the
future of healthcare by developing new approaches to treatment and educating
tomorrow's health professionals. Additionally, Cedars-Sinai demonstrates a
commitment to the community through programs that improve the health of its most
vulnerable residents.
With a growing number of primary urgent and specialty care locations across
Southern California, Cedars-Sinai’s medical network serves people near where
they live. Delivering coordinated, compassionate healthcare you can join our
network of clinicians and physicians to improve the healthcare people throughout
Los Angeles and beyond.