临床文档完整性专员（远程 - 罗斯维尔，CA）
Clinical Documentation Integrity Specialist (Remote - Roseville, CA)
位于萨克拉门托都会区，基督复临安息日会健康公司总部自40多年前便设在加利福尼亚州罗斯维尔。2019年，我们推出了获得WELL认证的园区——一个让全系统员工协作、创新和联系的焕新场所。
基督复临安息日会罗斯维尔医院及共享服务团队可以享受一个旨在促进健康并激发最佳工作的欢迎空间。
职位概述：
基督复临安息日会罗斯维尔医院正在寻找一名临床文档完整性专家，从事白班的临时按日计酬职位。我们希望找到一位具备资格且专注的人员，能够远程工作。理想的候选人将支持临床文档改进工作，确保医疗记录的准确、完整和合规，同时在虚拟环境中与临床和运营团队有效合作。
审查、评估和分析患者医疗记录，查找疾病的具体性、临床医生记录的准确性、编码要求以及重要医疗细节的记录，以确保患者医疗记录的总体质量和完整性，并确保其符合政府和其他法规。处理中等至多样范围的问题，需要对政策和指南进行一定程度的解读。运用对技术、原则、理论和概念的了解，完成常规和非常规任务。运行具有中等预算/影响的程序。
职位要求：
教育和工作经验：
- 专科/技术学位或同等教育/相关经验组合：必需
- 学士学位：优先考虑
- 三年临床经验：必需
- 两年临床文档经验：必需
资质证书：
- 认证临床文档专家（CCDS）或认证文档改进从业者证书（DIP）：必需
- 当前有效的注册护士、医疗提供者或同等资格：必需
核心职责：
- 审查和评估患者医疗记录，查找疾病的具体性、临床医生记录的准确性、编码要求以及重要医疗细节的记录，以确保患者医疗记录的总体质量和完整性。执行编码，进行DRG分配，并将所有审核活动录入跟踪系统。
查看英文原文
Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.
Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.
Job Summary:
Adventist Health Roseville is seeking a Clinical Documentation Integrity Specialist for a per diem temporary position on day shift. We are looking for a qualified and dedicated individual who can work remotely. The ideal candidate will support clinical documentation improvement efforts to ensure accurate, complete, and compliant medical record documentation while collaborating effectively with clinical and operational teams in a virtual environment.
Reviews, evaluates and assesses medical records of patients, looks for specificity of an illness, the accuracy of the clinician’s documentation, coding requirements and documentation of important medical details to ensure the overall quality and completeness of clinical documentation of the patient medical record and ensure it is in compliance with government and other regulations. Works on problems of moderate to diverse scope requiring some interpretation of policies and guidelines. Applies working knowledge of the techniques, principles, theories and concepts to complete routine and non-routine assignments. Runs program(s) with moderate budget/impact.
Job Requirements:
Education and Work Experience:
- Associate's/Technical Degree or equivalent combination of education/related experience: Required
- Bachelor's Degree: Preferred
- Three years' clinical experience: Required
- Two years' clinical documentation experience: Required
Licenses/Certifications:
- Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): Required
- Current licensed RN, medical provider or equivalent: Required
Essential Functions:
- Evaluates and assesses medical records of patients, looks for specificity of an illness, the accuracy of the clinician’s documentation, coding requirements and documentation of important medical details to ensure the overall quality and completeness of clinical documentation of the patient medical record. Performs coding, working DRG assignment and enters all review activity into tracking software.
- Analyzes and interprets medical records and clinical documentation and formulates appropriate physician queries. Performs follow up on incomplete physician queries to obtain an answer while the patient is still in house. Updates “working DRG” as documentation supports, or physician query answer supports a change in the DRG assignment.
- Reviews quality of medical record and communicates when conflicting data are found, the clinical documentation integrity specialist (CDIS) conveys deficiencies to the department lead for more information to resolve the conflict.
- Keeps abreast of regulatory changes related to documentation, coding and communicate these changes to appropriate staff. Follows documentation guidelines and legal requirements to ensure compliance with federal and state regulatory bodies. Attends ongoing education sessions.
- Acts as a liaison between the medical staff and the coding department. Works collaboratively with physicians and coding staff to ensure that clinical information in the medical record is present and accurate so that the appropriate clinical diagnosis and level of severity is captured for the level of service rendered to all patients. Attends scheduled physician and care management meetings as requested and reviews requested cases prior to the meetings.
- Performs other job-related duties as assigned.
Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
Adventist Health participates in E-Verify. Visit for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.
Originally posted on Himalayas