Kaiser Permanente Clinic Doc Improve Specialist in Honolulu, Hawaii
This position uses clinical knowledge of documentation requirements to improve overall health record quality, capture severity, acuity, and risk of mortality. This position includes the ability to perform concurrent and/or retrospective reviews of inpatient health records to evaluate clinical documentation for integrity and proper documentation of patient care. In addition, incumbent will need to have expertise in understanding the clinical documentation required for the completeness of the patient health record using a multidisciplinary team approach. The specialist will work in conjunction with the medical staff to facilitate appropriate clinical documentation of patient care.
Responsible for performing Clinical Documentation Improvement (CDI) chart reviews (concurrent, pre-bill and retrospective) for improving overall quality and completeness of clinical documentation for inpatient accounts.
Facilitate modifications to clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and health records coding staff to improve quality, accuracy, and completeness of clinical documentation in real-time.
Monitors the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcome data.
Communicates with members of the patient care team on clinical documentation improvement strategies and workflows, including a real-time physician escalation process and real-time concurrent notifications (utilization review, quality and risk management).
The candidate in this position will be instrumental with enhancing the overall quality completeness and accuracy of hospital health record documentation.
Validates Present on Admission (POA) indicators are verified and clearly documented for coding while the patient is still in-house.
Reviews clinical issues with medical coding staff to help them identify diagnoses that impact severity of illness (SOI) and risk of mortality (ROM) indicators for each patient.
Serves as an expert resource in reviewing all health records in support of consistent documentation for all payer types (i.e. Centers for Medicare & Medicaid Services (CMS), Medicare-Advantage, etc.) to assure complete and accurate diagnosis and procedure capture and coding.
Concurrent Reviews include: Reviews for completeness, contradictions, omissions, and accuracy of medical, surgical, pathological, pharmaceutical, diagnostic, and procedural documentation.
Identifies Do Not Bill Events (DNBE), Hospital Acquired Conditions (HAC), more definitive diagnosis, procedures, and quality indicators by communicating with Risk Management, Quality Management, Utilization Management, and Infection Control to address related issues.
Assists with training on clinical documentation improvement practices to physicians and key stakeholders.
Monitors verbal and written queries and conducts follow-up on queries and escalates as needed.
May perform patient care to the extent necessary to maintain clinical expertise, competency, and licensing necessary to fulfill job responsibilities and to direct the provision of care on the unit.
Provides direct patient care on an as needed basis. Provides services that are within scope of license and in compliance with all legal, regulatory, and policy requirements relevant to clinical role performed.
Incorporates the KP Nursing Vision, Model and Values throughout their Nursing Practice.
- Minimum three (3) years in-patient clinical or coding experience.
- Graduate from a school of nursing.
License, Certification, Registration
Valid Hawaii RN license (must meet education requirement(s) for Hawaii State licensure) upon hire.
ACDIS Certified Clinical Documentation Specialist Credential (CCDS) or AHIMA Certified Documentation Improvement Practitioner (CDIP). If not certified for CCDS, will need to be within 18 months upon hire.
Comprehensive understanding of a health records clinical content.
Ability to effectively communicate with physicians and other healthcare providers.
Excellent written, organizational and analytical skills required.
Competent computer skills in MS Word, Excel and PowerPoint and clinical systems required, familiar with 3M Coding and Reimbursement Systems, etc.
Excellent critical thinking skills, ability to prioritize work; strong communication skills and must be able to interact with all levels of healthcare professions.
Current credentialing from AHIMA accredited coding certification program for Certified Coder Specialist (CCS) or Registered Health.
Minimum two (2) years of experience as a Clinical Documentation Specialist preferred.
Familiar with coding classifications systems such as, but not limited to ICD-9 CM, ICD-10 MS-DRG, HCC preferred.
Graduate from a school of nursing, preferably a BSN preferred.
Licensure, certification, registration, related to clinical practice preferred.
Bachelor's degree in Nursing preferred.
Graduate from an accredited Health Information Technology/Informatics Program preferred.
Completion of an accredited health information coding program, with certification offered by AHIMA (American Health Information Management Association) preferred.
TITLE: Clinic Doc Improve Specialist
LOCATION: Honolulu, Hawaii
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.