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Clinical Documentation Education/Review Specialist, System Health Information Mgmt

Job ID 82257 Date posted 10/03/2017
  • Facility: Sharp HealthCare
  • City: San Diego
  • Department: System Health Information Mgmt
  • Category: Specialty Nurse Jobs
  • Job Status: Full-Time
  • Shift: Day Job
  • FTE: 1.0
  • Shift Start: 8 AM
  • Shift End Time: 4:30 PM
This position is located in Kearny Mesa (San Diego County).
8 hour - Day Shift
Required Skills and Qualifications
  • Minimum of two (2) years' with MS-DRGs and the Inpatient Prospective Payment System (IPPS)
  • Proven ability to ensure patient records are complete and are able to identify documentation opportunities for severity of illness and risk of mortality accurately and meet coding requirements
  • Effective ability and willingness to communicate benefits of complete and accurate documentation to physicians
  • Demonstrated ability to obtain documentation relevant to denials avoidance related to the Recovery Audit program, the Comprehensive Error Rate Testing (CERT) program, and other audit programs
  • Ability to work with all physician specialties in clinical documentation improvement initiatives, effectively tailoring learning and education opportunities to each physician specialty
  • Ability to collaborate with case managers to collaboratively capture patient severity of illness and intensity of service to ensure medical necessity
Preferred Skills and Qualifications
  • RN license and/or RHIA
  • CCDS/CDIS and/or CCS strongly preferred

The Second Level Review Specialist retrospectively reviews medical records to validate the appropriateness of coded data, based on clinical indicators; and identifies physician, and other healthcare provide documentation educational opportunities. Trends are monitored and reported to appropriate Management.  The Second Level Review Specialist provides coding expertise to staff within the organization to assist with accurate diagnosis and procedural coding and to ensure appropriate reflection of patient severity (ROI) and risk of mortality (ROM)
The Health Information Management Departments consists of Sharp Memorial Hospital and Sharp Mary Birch Hospital for Women and Newborns. The HIM departments provide service to both facilities which include release of information, optical imaging functions, coding and abstracting processes, data analysis and provides customer support to physicians and clinical care providers for EMR functions. Our EMR application is Cerner and On Base is utilized for Optical Imaging. This gives us the opportunity to provide patient information electronically to all of our providers across the continuum of care. For future technology Sharp HealthCare is going to utilize Computerized Assisted Coding and Front End Speech to compliment traditional dictation and transcription processes.
Sharp Memorial Hospital — the first hospital in San Diego with all private patient rooms — is dedicated to providing the highest-quality, patient-centered care and consists of 368 beds. Designed to promote comfort and healing with the use of natural light and soothing colors, the hospital offers the latest medical technology and is home to San Diego’s largest, most modern Emergency and Trauma Center.
Sharp Memorial is known for outstanding programs in cardiac and vascular care, cancer treatment, orthopedic and neurological services, rehabilitation, robotic surgery and multiorgan transplantation, and has been recognized as a MAGNET®-designated hospital for nursing excellence and is also designated as a Patient-Centered Hospital by Plane tree, an organization committed to personalizing, humanizing, and demystifying the hospital experience for patients and their families.
Essential Physical Requirements May Include
  • Sitting
  • Using Dual Monitors
  • Keyboarding
  • Using Mouse
  • Additional physical requirements of position may be discussed during interview.
    Sharp HealthCare is proud to be an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, gender identity, transgender status, sexual orientation, protected veteran status or any other protected class.
    Keywords;  Clinical Documentation Education Review Specialist, Sharp Jobs, Sharp Careers, Coder, Coding, healthcare jobs

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