Pediatric Clinical Documentation Specialist
Location: Fountain Valley, California
Job Listing: MEM005999
Pediatric CDI Reviewer
The Clinical Documentation Specialist assesses and reviews a patient’s medical records to ensure that all the information documented reflects the patient’s severity of illness, clinical treatment, and the accuracy of documentation. Part of the role is to perform concurrent reviews of medical records, clinically validate diagnosis codes, identify missing diagnosis, and query physicians and other healthcare providers for more specifics so documentation accurately reflects the patient’s severity of illness. This is a remote position, requiring on site visits less than 2 times per month.
Essential Job Outcomes:
- Completes initial concurrent review process and subsequent reviews for all selected admissions to initiate the clinical documentation review process and documents findings. Identifies opportunities with regard to utilization guidelines, quality of care and patient safety.
- Identifies opportunities and records principle and secondary diagnoses, principle procedures and assigns a working DRG. Collaborates with the medical record coders and CDI Coordinators to determine a working and final DRG representing accurate severity of illness, treatment and intensity of care.
- Queries the medical staff and other members of the healthcare team to obtain accurate and complete chart documentation that appropriately supports the severity of the patient’s illness.
- A minimum of 5 years clinical experience in specialty area (Peds, NICU etc....) preferred.
- Experience in quality assurance, chart review, and auditing is also preferred.
- Knowledge and previous use of the 3M coding software and electronic health record (EPIC) is preferred.
- Pediatric CDI experience is highly desired!
- Bachelor’s degree or higher in Nursing or health-care related field.
- California Licensed healthcare professional. Current RN, NP, PA, or MD preferred.
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"I love working at Miller Children's & Women's Hospital Long Beach because I value working for a company that invests in its employees and the community we serve. From the support and guidance I receive from managers who value my professional and personal growth; to being able to work alongside colleagues who are dedicated to help their patients and families. I feel inspired every day to do the work that I love alongside people who share a similar vision."