Documentation Specialist jobs in San Diego, CA

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The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

• 3 Years Experience in a Clinical Documentation Improvement role
• California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED

• Obtain certification as a Certified Clinical Documentation Specialist (CCDS)

• Act as a mentor
  Acts as a mentor for new CDISs, including answering questions, providing direction, oversight peer review of CDIS Case Reviews to ensure, accuracy and appropriate, non-leading queries.
  Provides performance feedback to the CDIS as well as the CDI Director.
  Collaborates with the CDIS team to develop the monthly work coverage schedule to ensure work day CDI coverage (does not include holidays or weekends).
  Distributes the calendar to the team and the Director.
  Other duties as assigned.
• Coding
  Interacts with Clinical Coding Specialists and establishes a strong, collaborative relationship with the coding team.
  Facilitates physician queries and assists in obtaining clinically complete and specific documentation needed for compliant coding.
  Assures any clarification is documented appropriately in the patient's record according to policy.
  Follows-up with physician, if appropriate.
• Coding compliance
  Abides by all documentation and coding conventions, ethical and professional standards and rules established by the Center for Medicare and Medicaid (CMS), and the American Health Information Management Association (AHIMA) for assignment of diagnostic and procedural codes and ultimately a working DRG.
  Adheres to AHIMA query guidelines.
  Remains current with coding and documentation improvement techniques to support accuracy of codes and the resulting working DRG assigned.
  Participates in educational programs and in-services in order to maintain and exceed excellence in documentation and coding skills.
  Information will include the AHA Coding Clinic publication, pharmacology, laboratory, disease processes, and new/emerging technologies.
• Collaboration
  Collaborates with Clinical Informaticists, Physician Informaticists, and Specialists regarding EMR documentation education and system improvements.
  Demonstrates content expertise regarding applications and business operations by supporting clients and receiving customer feedback.
  Manages client expectations, priorities, and attainment of project goals through effective communication.
  Recommends workflow and technical improvements to various electronic documentation tools.
• Communication and teamwork
  Demonstrates positive interpersonal relations in dealing with all members of the team (i.e. co-workers, supervisors, physicians, etc.) as evidenced by: a) Communicating in a positive and productive manner; b) Demonstrating respect for team members; c) Maintaining a positive attitude about assignments and team members; and d) Working collaboratively and cooperating with other departments/units.
  Peer review of CDIS queries to ensure clarity, accuracy and meets professional guidelines.
• Documentation
  
  Improves accuracy documentation specificity and completeness with real-time interactive communication and education of physicians, clinicians, and other involved parties regarding the necessity of providing complete and clear documentation of the care provided throughout a patient's stay.
  This includes day to day processes of working daily with physicians to improve documentation capture of diagnosis specificity, all secondary diagnoses, and procedures during the patient stay.
  This is achieved using clinical knowledge to deploy queries, face-to-face communications, and/or other educational programs and tools useful and necessary to achieve this goal.
• Quality
  Interacts with the Quality Specialists and establishes a strong, collaborative relationship with the quality team.
  Notifies Quality of any potential Hospital Acquired Conditions or Patient Safety indicators which need to be investigated and potentially mitigated or confirmed as appropriate.
  Assures any clarification is documented appropriately in the patient's record according to policy.
  Follows-up with physician, if appropriate.

• Performs at or above CDIS Productivity Standards.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class