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Clinical Documentation Integrity Specialist - FT - Days - Clinical Documentation Integrity at El Camino Hospital

Posted in Other 30+ days ago.

Location: Mountain View, California

Job Description:

El Camino Health is committed to hiring, retaining and growing the best and brightest professionals who will carry our mission and vision forward. We are proud of our reputation in the community: One built on compassion, innovation, collaboration and delivering high-quality care. Come join the team that makes this happen.



Scheduled Bi-Weekly Hours


Work Shift

Day: 8 hours

Job Description

To utilize specialized clinical, coding and compliance knowledge to support physicians and other health care providers to improve overall quality and completeness of clinical documentation throughout the El Camino Health System using a multidisciplinary approach.. Works collaboratively with medical, nursing and ancillary staffs, HIMS coders and quality team to ensure that the clinical information within the medical record is accurate, complete, specific, consistent, non-conflicting and compliant. This includes accurate documentation to support the capture of DRGs, Hierarchical Condition Categories (HCC), ICD 10-CM / PCS / CPT specificity, APR SOI/ROM and clinical validation of inpatient and outpatient clinical conditions to support the level of care. . Educates members of the patient care team both formally and informally regarding documentation guidelines, coding requirements and service specific requirements. Involved in projects that support enterprise-wide goals and objectives to improve clinical documentation and quality of care.

The Clinical Documentation Specialist facilitates clarification of clinical documentation through concurrent and retrospective interaction with physicians and other members of the health care team to support the capture of appropriate clinical complexity for the level of service rendered to all patients.

Key Responsibilities:

  • Provide daily clinical review of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans;

  • Be responsible for the day-to-day review of documentation by the Medical Staff and healthcare team in accordance with the hospital's designated clinical documentation policies, internal procedures, official coding guidelines and ACDIS/AHIMA recommendations;

  • Communicate with physicians, face to face or via clinical documentation query forms, regarding missing, unclear conflicting, non-specific, clinically non-congruent medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness;

  • Communicate and educate appropriate healthcare team members to ensure accurate, complete, and compliant documentation in the medical record is ensured;

  • Demonstrate an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, HCCs, RAF scores, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team;

  • Gather and analyze information pertinent to documentation findings and outcomes;


Bachelor's degree in Nursing or graduate of a medical school with a medical doctorate degree from inside or outside the U.S;

Minimum of two (2) years of experience as a clinical documentation specialist;

Five (5) years of acute direct clinical experience.

Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting as well as outpatient encounters (observation, ED, ACS, etc.);

Professional Coding Certification (CRC, CCS, CPC) or Medical Coding experience more than 3 years preferred;

Proficiency in computer usage including database and spreadsheet analysis, presentation programs, word processing and Internet searching;

Knowledge of federal, state and fiscal intermediary regulations.

License/Certification/Registration Requirements

Valid U.S. RN License OR Medical Doctorate;

Certified Clinical Documentation Specialist (CCDS) Credential or Clinical Documentation Integrity Practitioner required;

Required to obtain Certified Clinical Documentation Specialist - Outpatient (CCDS-O) within 24 months of hire

The Physical Requirements and Working Conditions of this job are available. El Camino Health will provide reasonable accommodations to qualified individuals with a disability if that will allow them to perform the essential functions of a job unless doing so creates an undue hardship for the hospital, or causes a direct threat to these individuals or others in the workplace which cannot be eliminated by reasonable accommodation.

Sedentary Work - Duties performed mostly while sitting; walking and standing at times. Occasionally lift or carry up to 10 lbs. Uses hands and fingers. - (Physical Requirements-United States of America)

An Equal Opportunity Employer:
El Camino Health seeks and values a diverse workforce. The organization is an equal opportunity employer and makes employment decisions on the basis of qualifications and competencies. El Camino Health prohibits discrimination in employment based on race, ancestry, national origin, color, sex, sexual orientation, gender identity, religion, disability, marital status, age, medical condition or any other status protected by law. In addition to state and federal law, El Camino Health also follows all applicable fair and equitable employment policies from the County of Santa Clara.

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