Clinical Documentation Specialist

City of Hope
$42.40 - $59.36 / hr
United States, California, Duarte
1500 East Duarte Road (Show on map)
Mar 05, 2025
Join the transformative team at City of Hope, where we're changing lives and making a real difference in the fight against cancer, diabetes, and other life-threatening illnesses. City of Hope's growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, and treatment facilities in Atlanta, Chicago and Phoenix. Our dedicated and compassionate employees are driven by a common mission: To deliver the cures of tomorrow to the people who need them today. Position Summary: Coding and CDI certification Clilnical documentations improvement Coder consultant working at an institution - 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. As a successful candidate, you will: 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. Qualifications Your qualifications should include: 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. Successful completion of required education courses. CCS, CDIP or CCDS required City of Hope is an equal opportunity employer. To learn more about our commitment to diversity, equity, and inclusion, please click here. To learn more about our Comprehensive Benefits, please CLICK HERE.