Clinical Documentation Specialist (1.0FTE, Days)

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Category: Quality
Job Type: Full-Time
Shift: Days
Req: 13762
FTE: 1


1.0FTE, 8 Hour Day Shift

At Stanford Children’s Health, we know world-renowned care begins with world-class caring. That's why we combine advanced technologies and breakthrough discoveries with family-centered care. It's why we provide our caregivers with continuing education and state-of-the-art facilities, like the newly remodeled Lucile Packard Children's Hospital Stanford. And it's why we need caring, committed people on our team - like you. Join us on our mission to heal humanity, one child and family at a time.

Job Summary

The Clinical Documentation Quality Specialist is responsible for conducting clinically based concurrent and retrospective reviews of both inpatient and outpatient medical records to evaluate the clinical documentation of clinical services. The individual will work closely with physicians and hospital staff to facilitate appropriate clinical documentation of patient care. This position plays a key role in reporting quality of care outcomes and in obtaining complete, accurate, and compliant documentation for appropriate reimbursement for services provided and capture of clinical outcome measures.

Essential Functions

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned. Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patients' rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings. Must perform all duties and responsibilities in accordance with the Service Standards of the Hospital(s).

  • Address abnormal ancillary test findings when they occur and query physicians regarding the impact on patient care and DRG assignment

  • Gathers and analyzes clinical and financial information from a variety of internal and external sources, relating to patient safety, utilization of resources, physician practice patterns, system problems, and other quality functions. Identifies trends, variances, deficiencies, and problems utilizing aggregated data and information

  • Initiate physician interaction when ambiguous or conflicting information is in the medical record, providing guidance to Case Management, physicians, and hospital staff regarding documentation for correct coding and compliance necessary for increased CMI, decreased LOS, and optimal resource utilization

  • Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, medical staff, ancillary staff, and HIM coding staff utilizing Joint Commission, Federal and State regulations

  • Perform monthly retrospective reviews for DRG verification with focus upon questionable DRGs focused OIG work plan and CMS, also performing any organizational trends or patterns noted

  • Utilizes ICD-9-CM hospital coding policies and procedures, Federal and State coding reimbursement guidelines, and application of the Coding Clinic Guidelines to assign working DRG, reviewing patient records throughout hospitalization that have been identified as focus DRG by regulatory agencies or the facility to ensure the codes are reported at the highest specificity

  • Verifies appropriateness of assigned admission status communicating all discrepancies to Admitting Services for immediate correction

Minimum Qualifications

Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.

Education: Bachelor's degree in a work-related discipline/field from an accredited college or university

Experience: Five (5) years of progressively responsible and directly related work experience

License/Certification: CA Registered Nurse (RN) OR Registered Health Information Technician (RHIT) OR Registered Health Information Administrator (RHIA) certification by the American Health Information Management Association (AHIMA)

Knowledge, Skills, and Abilities

These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification.

  • Ability to communicate effectively, using excellent verbal and written skills, as well as apply critical thinking, creative problem-solving, and conflict management skills

  • Ability to perform accurate clinical chart abstractions and initiate documentation queries based on clinical signs, symptoms, diagnostic findings and treatment

  • Ability to understand and correlate the significance of clinical documentation to compliance with Joint Commission guidelines, core measures, National Patient Safety Goals (NPSG), and AHRQ patient safety indicator measures

  • Ability to work productively and cooperatively with individuals at all levels of the organization, including physicians, HIM/coders, and quality managers/analysts

  • Knowledge of coding clinic guidelines, ICD-9-CM official guidelines for coding and reporting, AHIMA standards of ethical coding, and AHIMA query guidelines

  • Knowledge of MS-DRG and APR-DRG systems, which includes CC/MCC impact, severity of illness, risk of mortality, role of principal and secondary diagnosis, and impact of procedures on DRG

  • Knowledge of personal computers and proficiency in the use of software applications such as Microsoft Word, PowerPoint and Excel

  • Knowledge of quality and patient safety principles and processes



Equal Opportunity Employer

Lucile Packard Children’s Hospital Stanford strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, LPCH does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements, and where applicable, in compliance with the San Francisco Fair Chance Ordinance.