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
https://adventisthealth.org/careers/everify/ 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.
Adventist Health is a faith-based, nonprofit, integrated health system serving
more than 100 communities on the West Coast and Hawaii with over 440 sites of
care, including 27 acute care facilities. Founded on Adventist heritage and
values, Adventist Health provides care in hospitals, clinics, home care, and
hospice agencies in both rural and urban communities. Our compassionate and
talented team of more than 38,000 includes employees, physicians, Medical Staff,
and volunteers driven in pursuit of one mission: living God's love by inspiring
health, wholeness and hope.