Clinical Documentation Specialist

🔥 11 minutes ago

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City of Hope

WebsiteLinkedInAll Job Openings

10,000+ employees

🧬 Biotechnology

🔬 Science

🤝 Non-profit

💰 $5.4M Grant - City of Hope on 2024-05

Biotechnology • Science • Non-profit

City of Hope is a nonprofit, NCI-designated comprehensive cancer center and research hospital near Los Angeles that provides patient care, conducts translational biomedical research, and offers education and clinical trials across a national network. It focuses on cancer, diabetes, and other life‑threatening diseases, combining clinical services, laboratory science, training and community outreach to develop new treatments and support patients and families.

📋 Description

• Facilitate improvements in clinical documentation quality, completeness, and accuracy to support patient care and reimbursement outcomes. • Analyze clinical records and identify documentation opportunities related to severity of illness, risk of mortality, and coding accuracy. • Assign working DRGs for inpatient admissions and support appropriate code assignment. • Collaborate with physicians, Nurse Case Managers, and multidisciplinary care teams to obtain complete and accurate clinical documentation. • Query providers to clarify incomplete, conflicting, or ambiguous documentation using approved processes. • Perform clinical record abstracting and data collection to support reimbursement, quality initiatives, and outcome reporting. • Educate physicians and care teams on documentation standards, coding updates, MS-DRG changes, and coding guidelines. • Ensure the accuracy and integrity of medical record data prior to billing and claims submission. • Partner with Patient Accounting and coding teams to resolve reimbursement and documentation-related issues. • Support quality management and continuous improvement initiatives through data analysis, education, and documentation integrity efforts.

🎯 Requirements

• Associate’s or Bachelor’s degree in Health Information Management and/or a Certified Coding Specialist (CCS) credential. • Minimum of two years of inpatient clinical coding experience or successful completion of a coding competency assessment. • CCS, CDIP, or CCDS certification required. • Familiarity with concurrent coding models strongly preferred. • Proficiency with Encoder/Grouper technology and strong computer skills. • Understanding of clinical documentation improvement (CDI) principles and coding compliance requirements. • Ability to effectively communicate and collaborate with physicians and interdisciplinary teams. • Strong analytical, critical thinking, and problem-solving skills. • Commitment to maintaining data integrity, coding accuracy, and regulatory compliance. • Nursing degree and/or registered nurse experience preferred.

🏖️ Benefits

• Comprehensive Benefits