The specialist reviews and evaluates patient medical records to ensure documentation specificity, accuracy, coding compliance, and completeness, ensuring adherence to all relevant regulations. This involves performing coding, updating DRG assignments, formulating physician queries, and acting as a liaison between medical staff and the coding department.
Requirements summary
Candidates must possess an Associate's/Technical Degree or equivalent experience, along with three years of clinical experience and two years of clinical documentation experience. Required certifications include CCDS or DIP, and the applicant must hold a current licensed RN, medical provider, or equivalent status.
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: 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.
