Adventist Health
Clinical Documentation Integrity Specialist (Hybrid - Bakersfield...
Adventist Health - Bakersfield, California, United States, 93399
Work at Adventist Health
Overview
- View job
Overview
Clinical Documentation Integrity Specialist (Hybrid - Bakersfield, CA)
1 week ago Be among the first 25 applicants Job Description
Central to all that California has to offer, Adventist Health Bakersfield has been providing an extraordinary team of world-class physicians, top-notch medical technology, caring professionals and award-winning quality since 1910. We are comprised of a 254-bed acute care hospital and 20 primary and specialty care medical offices. As one of America's fastest growing cities, Bakersfield offers affordable housing on the West Coast, beautiful weather, high-quality education and it is just a few hours away from Yosemite and Sequoia National Parks, the Central California Coast and Southern California’s great sports, theaters, concerts and amusement parks. Job Description
Central to all that California has to offer, Adventist Health Bakersfield has been providing an extraordinary team of world-class physicians, top-notch medical technology, caring professionals and award-winning quality since 1910. We are comprised of a 254-bed acute care hospital and 20 primary and specialty care medical offices. As one of America's fastest growing cities, Bakersfield offers affordable housing on the West Coast, beautiful weather, high-quality education and it is just a few hours away from Yosemite and Sequoia National Parks, the Central California Coast and Southern California’s great sports, theaters, concerts and amusement parks.
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 Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): Required Foreign Medical Doctor (FMD) or Medical license MD (MD) or Registered Nurse (RN): 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, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.
About Us
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. Seniority level
Seniority level Mid-Senior level Employment type
Employment type Full-time Job function
Job function Health Care Provider Industries Hospitals and Health Care Referrals increase your chances of interviewing at Adventist Health by 2x Refill Support Specialist - Outpatient Medication Refill Department
Bakersfield, CA $44.73 - $64.85 3 weeks ago Bakersfield, CA $44.73 - $64.85 1 week ago Adjunct RN (Med Surg) Clinical Instructor- Marsha Fuerst School of Nursing- Bakersfield
Adjunct RN (Med/Surg) Clinical Instructor - Marsha Fuerst School of Nursing - Bakersfield
Adjunct RN OBGYN Clinical Instructor - Marsha Fuerst School of Nursing - Bakersfield
Adjunct RN Pediatrics Clinical Instructor - Marsha Fuerst School of Nursing - Bakersfield
Adjunct RN Theory Instructor (Med-Surg) - MFSON Bakersfield
Adjunct RN (Med Surg) Instructor -Marsha Fuerst School of Nursing - Bakersfield, CA
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr
1 week ago Be among the first 25 applicants Job Description
Central to all that California has to offer, Adventist Health Bakersfield has been providing an extraordinary team of world-class physicians, top-notch medical technology, caring professionals and award-winning quality since 1910. We are comprised of a 254-bed acute care hospital and 20 primary and specialty care medical offices. As one of America's fastest growing cities, Bakersfield offers affordable housing on the West Coast, beautiful weather, high-quality education and it is just a few hours away from Yosemite and Sequoia National Parks, the Central California Coast and Southern California’s great sports, theaters, concerts and amusement parks. Job Description
Central to all that California has to offer, Adventist Health Bakersfield has been providing an extraordinary team of world-class physicians, top-notch medical technology, caring professionals and award-winning quality since 1910. We are comprised of a 254-bed acute care hospital and 20 primary and specialty care medical offices. As one of America's fastest growing cities, Bakersfield offers affordable housing on the West Coast, beautiful weather, high-quality education and it is just a few hours away from Yosemite and Sequoia National Parks, the Central California Coast and Southern California’s great sports, theaters, concerts and amusement parks.
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 Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner Certificate (DIP): Required Foreign Medical Doctor (FMD) or Medical license MD (MD) or Registered Nurse (RN): 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, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.
About Us
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. Seniority level
Seniority level Mid-Senior level Employment type
Employment type Full-time Job function
Job function Health Care Provider Industries Hospitals and Health Care Referrals increase your chances of interviewing at Adventist Health by 2x Refill Support Specialist - Outpatient Medication Refill Department
Bakersfield, CA $44.73 - $64.85 3 weeks ago Bakersfield, CA $44.73 - $64.85 1 week ago Adjunct RN (Med Surg) Clinical Instructor- Marsha Fuerst School of Nursing- Bakersfield
Adjunct RN (Med/Surg) Clinical Instructor - Marsha Fuerst School of Nursing - Bakersfield
Adjunct RN OBGYN Clinical Instructor - Marsha Fuerst School of Nursing - Bakersfield
Adjunct RN Pediatrics Clinical Instructor - Marsha Fuerst School of Nursing - Bakersfield
Adjunct RN Theory Instructor (Med-Surg) - MFSON Bakersfield
Adjunct RN (Med Surg) Instructor -Marsha Fuerst School of Nursing - Bakersfield, CA
We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.
#J-18808-Ljbffr