Clinical Documentation Specialist

Job Summary:

The Clinical Documentation Specialist plays a critical role in ensuring the accuracy and completeness of patient medical records. They review and analyze clinical documentation to ensure it meets regulatory and quality standards. Actively and consistently contributes to department operations and communications, behaves in a manner consistent with the mission, vision, and values of Pipeline Health, upholding standards of AIDET (Acknowledge, Introduce, Duration, Explanation, Thank you) patient communication.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.

Essential Functions:

• Review and analyze physician documentation, including progress notes, discharge summaries, and operative reports.
• Identify and query missing or inaccurate information with physicians and other healthcare providers.
• Assign appropriate ICD-10-CM and CPT codes to diagnoses and procedures.
• Ensure documentation complies with regulatory requirements, including HIPAA and The Joint Commission standards.
• Participate in clinical documentation improvement (CDI) initiatives.
• Educate and train healthcare providers on documentation best practices.
• Stay up to date on changes to medical terminology, coding guidelines, and regulatory requirements.
• Uses clear, concise, professional communication with coworkers, patients, all customers internal and external.
• Uses AIDET in interactions with patients and family members.
• Acts with a sense of urgency when performing tasks.
• Basic unit/department maintenance such as keeping files, drawers, cabinets free from unnecessary clutter.
• Reports on any equipment and or environmental issues for repair.
• Abides by HIPAA (Health Insurance Portability and Accountability Act) regulations.
• Speaks up to stop the line and escalates potential safety events if necessary.
• Completes and attends monthly training assigned.
• Other duties as assigned.

Behavioral Standards:

• Treats everyone as their customer; utilizes scripting and other tools to ensure consistency in customer service; Expresses recognition and shows appreciation to others; fully utilizes AIDET principles; responds quickly to handle requests, complaints, and questions; displays a positive attitude.
• Demonstrates the highest level of professionalism, passion and care when interacting with patients, families, physicians, and hospital staff members.
• Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential, embracing ingenuity to service our customers.

Communication/Knowledge:

• Strong understanding of medical terminology, coding guidelines, and clinical workflows.
• Wears nametag properly; follows dress code policy; answers phone correctly and promptly; is prepared for meetings; meets deadlines; does not participate in gossip; acts ethically and treats others with respect; respects customer’s and co-worker’s time; establishes and maintains effective relationships with customers and co-workers.

Collaboration/Teamwork:

• Attends staff meetings; follows HIPAA guidelines; follows patient rights policy; complies with the compliance program; demonstrates knowledge of role in a disaster; demonstrates knowledge of fire and fire drill procedures; working knowledge of hospital emergency codes; always utilizes standard precautions in the clinical setting; safely manages the environment of care by demonstrating a working knowledge of the requirements of the: Life Safety program, Utilities Management program, Hazardous Materials program, Emergency Preparedness program, Safety Management program, Medical Equipment Management program, Security Management program.

Qualifications/Experience:

• Minimum of two (2) years of experience in clinical documentation or coding.
• Strong understanding of medical terminology and coding guidelines.
• Proficient in Microsoft Office Suite and electronic health record (EHR) systems.
• Critical thinking, service excellence and good interpersonal communication skills, ability to read/comprehend written instructions, strong organizational skills, ability to follow verbal instructions, and PC (computer) skills.
• A capacity to learn, synthesize, make critical judgments, work independently, place patients and families first, and collaborate with the team members who are recognized leaders within healthcare.