Clinical Documentation Improvement Specialist - RUHS - Medical Records at County of Riverside in Moreno Valley, California

Job Description:

ABOUT THE POSITION

The County of Riverside - Riverside University Health System-Medical Center is seeking a Clinical Documentation Improvement Specialist for our Medical Records department. The work schedule for this position is a 9/80 from 7:00am-4:30pm working mostly remote, with occasionally coming into the office.

The most competitive candidates will have experience with EPIC and 3M Clinical Documentation Integrity Services.

Meet the Team!
Riverside University Health System-Medical Center consistently receives national recognition for its progressive and innovative care, as well as being known as one of the top employers in the region. The 439-bed Medical Center is a designated Stroke Center, Level II Trauma Center, and the only Pediatric ICU in the region. Can you see yourself here? For more information on RUHS-Medical Center, please visit www.ruhealth.org

EXAMPLES OF ESSENTIAL DUTIES
• Complete admission reviews of patients' records within 24-hours of admission to evaluate and analyze documentation in order to assign the principal diagnosis, pertinent secondary diagnoses, and procedures for accurate and optimal CMS-Diagnostic Related Group (CMS-DRG) assignment.

• Initiate and perform concurrent documentation reviews of selected inpatient and outpatient records to clarify conditions/diagnoses and procedures where inadequate or conflicting documentation exists, and conduct follow-up reviews as necessary.

• Develop and implement methods of improving the clarity, accuracy, and completeness of clinical documentation; monitor and evaluate coding outcomes and provide periodic status to medical center departments and committees.

• Communicate with and serve as a resource for physicians, nurses, and other healthcare providers to facilitate complete and accurate documentation of the patient record; query physicians regarding missing, unclear, or conflicting medical record documentation and obtain additional documentation; keep physician leaders informed of pertinent data, documentation trends, and opportunities for learning and improvement related to documentation integrity.

• Code a wide variety of procedures and primary and secondary diagnoses according to the applicable International Classification of Diseases (i.e., ICD-10-CM or subsequent adaptation) coding system and CPT-4 procedural coding system; prepare pertinent data from medical charts according to criteria established by the Office of State Wide Hospital Planning and Development (OSHPD) and the Medical Audit Committee or individual physicians for various studies, statistical indexing, and preparation of summary reports to various regulatory agencies.

• Collect data for performance improvement and report findings and outcomes; participate in the analysis and trending of statistical data for specified patient populations to identify opportunities for improvement.

• Participate in revenue cycle meetings, providing data relative to reimbursement concerns; educate physicians and healthcare providers regarding documentation matters related to coding, billing, and reimbursements.

MINIMUM QUALIFICATIONS
OPTION I

Education: Graduation from an accredited college or university with a Bachelor's degree in nursing.

Experience: Three years of Registered Nurse experience in an acute care hospital.

License/Certificate: Must possess and maintain a current valid license to practice as a Registered Nurse in the State of California.

Possession of valid Basic Life Support (BLS) Cardiopulmonary Resuscitation (CPR) and Automated External Defibrillator (AED) certificates issued by the American Heart Association for professional healthcare providers.

OPTION II

Education: Graduation from an accredited college or university with a Bachelor's degree in Health Information Management or Health Information Technology.

Experience: Four years of professional coding and abstracting medical records in an acute care hospital.

Certificate: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician, or Registered Health Information Administrator issued by the American Health Information Management Association.

OPTION III

Education: Completion of Doctor of Medicine degree.

Experience: One year of clinical documentation improvement experience in a healthcare setting.

Certificate: Possession of valid certification as a Certified Coding Specialist (CCS), Registered Health Information Technician, or Registered Health Information Administrator issued by the American Health Information Management Association. Certification in Clinical Documentation preferred.

Knowledge of: Coding, abstracting, and terminology systems such as: International Classification of Diseases, Clinically Modified (ICD-10), and Current Procedural Terminology (CPT- 4); comprehensive medical terminology covering a wide variety of medical specialties; clinical documentation standards; federal, state, and local laws and regulations governing professional aspects of nursing; payor source documentation requirements and governmental regulations affecting reimbursement.

Ability to: Analyze and interpret the technical elements of a medical chart; analyze, code, and abstract complex technical data from medical records covering a wide variety of medical specialties utilizing an encoder and electronic abstracting system; prepare and maintain concise and complete records and reports; establish and maintain effective working relationships with physicians, patients and fellow employees; effective communication skills.

SUPPLEMENTAL INFORMATION
Condition of Employment

In accordance with the California Department of Public Health Order dated August 5, 2021, health care facility workers who work in indoor settings where care is provided to patients or where patients have access for any purpose must be vaccinated against COVID-19 as follows: first dose of a one-dose regimen or second dose of a two-dose regimen, by September 30, 2021. Consideration may be given to candidates who are in the process of completing their vaccination regimen.

The Order allows for workers to be exempt from the vaccination requirements by providing the facility with a declination form signed by the individual stating either of the following: (1) the worker is declining vaccination based on Religious Beliefs; or (2) the worker is excused from receiving any COVID-19 vaccine due to Qualifying Medical Reasons. Workers who are exempted from the vaccination requirements must observe all other infection control requirements, including face coverings and regular COVID testing at the frequency required by their work site.

A requirement of employment is to provide proof of COVID-19 vaccination, or a completed COVID-19 Vaccination Declination form (filled out by the candidate and their medical provider as appropriate), during the pre-employment process. Failure to submit the required documentation may render a candidate ineligible to move forward in the process.

VETERANS PREFERENCE:
The County has a Veterans Preference Policy. Upload a copy of your (or your spouse's) Member-4 Form DD-214 (or NGB-22). of your spouse's letter of disability (if applicable) with your application. For privacy reasons, it is recommended that you remove your social security information from the document(s). A Human Resources Representative will review the materials and determine if you qualify for veterans' preference. Policy is available here .

What's Next?
Open to All Applicants
This recruitment is open to all applicants.Applicants who are current employees of the Department of RUHS-Medical Center may be considered before other applicants depending on the volume of applications received.

Based on the number of applications received, this posting may close without notice.

MEDICAL/DENTAL/VISION INSURANCE: A choice of different medical, dental and visions plan are available to elect. The County provides a Flexible Benefit Credit contribution as governed by the applicable SEIU Memorandum of Understanding to contribute towards the cost of these plans.

Note: Employees on assignment through the Temporary Assignment Program (TAP) receive different benefits. See the list here .
MISCELLANEOUS RETIREMENT: County of Riverside has three retirement Tiers through the California Public Employees' Retirement System (CalPERS).

• 
  Tier I (Classic Member - Formula 3% @ 60): Applicable to current and former County of Riverside local miscellaneous employees hired prior to 08/24/2012 and did not withdraw CalPERS contributions. The employee contribution is eight (8%) percent.


• 
  Tier II (Classic Member - Formula 2% @ 60): Applicable to local miscellaneous employees 1) hired after 08/23/2012 through 12/31/2012; 2) Previously employed with another CalPERS contracting public agency or a reciprocal retirement system, with a break in service of less than six months between the separation date with the previous employer and the appointment date with the County of Riverside. The employee contribution is seven (7%) percent.


• 
  Tier III (PEPRA New Member - Formula 2% @ 62): Applicable to CalPERS local miscellaneous new members hired on or after the implementation of the Public Employees' Pension Reform Act of 2013 (PEPRA) which took effect January 1, 2013. As of July 1, 2020, the employee contribution is 7.25% and subject to change annually.

A new member is defined as any of the following:

A new hire who enters CalPERS membership for the first time on or after January 1, 2013, and who has no prior membership in any California Public Retirement System.

A new hire who enters CalPERS membership for the first time on or after January 1, 2013, and who was a member with another California Public Retirement System prior to that date, but who is not subject to reciprocity upon joining CalPERS.

A member who first established CalPERS membership prior to January 1, 2013, and who is rehired by a different CalPERS agency after a break in service of greater than six (6) months.

CalPERS refers to all members that do not fit within the definition of a new member as "classic members".

Contribution rates are subject to change based on the County of Riverside annual actuarial valuation.

Note:

This summary is for general information purposes only. Additional questions regarding retirement formulas can be sent to retirement@rivco.org or by calling the Benefits Information Line at (951) 955-4981,
Option 2.

If you have prior service credit with another CalPERS agency or within agencies, please contact CalPERS at (888) 225-7377 to determine which retirement tier would be applicable to you. CalPERS is governed by the Public Employees' Retirement Law. The Retirement Law is complex and subject to change. If there's any conflict between this summary and the law, the law will prevail over this summary.
DEFERRED COMPENSATION: Voluntary employee contribution with a choice between two 457 deferred compensation plan options.

VACATION ACCRUAL (Bi-Weekly Accrual):

0< 3 year = 80 Hours (10 Days)

4< 9 years = 120 Hours (15 Days)

10 or more years = 160 Hours (20 Days)

Maximum Vacation leave accumulation is 480 hours.

SICK LEAVE: Four (4) hours Sick Leave accrual per pay period with unlimited accrual.

HOLIDAYS: Normally 12 paid holidays per year.

BEREAVEMENT LEAVE: Allowed 5 days (3 days are County paid; 2 additional days can be taken from accrued Sick Leave balance).

BASIC LIFE INSURANCE: Equal to one times annual base salary not to exceed $50,000 of term life coverage. Premiums are paid by the County. Additional Supplemental Life plan is available for employee purchase.

DISABILITY: Short-term Disability benefit pays up to a maximum of $461.54 weekly, payable up to a maximum of 52 weeks.

POST RETIREMENT MEDICAL CONTRIBUTION: A monthly contribution is made by the County towards retiree health insurance offered through the County as governed by the applicable SEIU Memorandum of Understanding.

OTHER: There may be other benefit provisions as specified in the applicable Memorandum of Understanding. Please contact the recruiter listed on the job posting directly for more information.

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