Under the general direction of the HID CDI/Core Measures Supervisor, the Clinical Documentation Specialist has two primary areas of responsibility. Within the Clinical Documentation Integrity program (CDI), the CDS is responsible to assist physicians in improving the overall quality and completeness of clinical documentation. Within the CORE Measure/Regulatory Review program (CORE), the CDS is responsible for reviewing and assessing the clinical and non-clinical documentation for compliance with The Joint Commission (TJC), hospital and state/federal regulatory requirements.
Primary Duties and Responsibilities
Performs record review (quantitative and qualitative) and assesses the level of compliance with stated regulatory requirements by area of job focus. Assigns a working MS-DRG/APR-DRG or diagnosis specific review criteria for CORE measure decision trees within the set time frames. May also review inpatient and outpatient records as part of the hospital wide medical record review program for the Joint Commission. Captures and maintains the related review data in designated computer systems or databases.
Assists in clarifying clinical information used for measuring and reporting physician and medical center outcomes which incorporates current DRG methodologies (e.g. MS-DRGs, etc.) by CMS and/or other regulatory/quality reporting bodies (e.g. APR-DRGs, SOI, ROM, etc). Issues queries to members of the patient care team - primarily physicians - regarding possible diagnoses or to improve the specificity of diagnoses thru enhanced clinical documentation. Facilitates modifications to clinical documentation as needed to support component stated previously.
Leads or provides education/training to clinical care (physicians, nurses, etc.) and administrative support team members regarding the clinical documentation requirements essential for demonstrating quality patient care (SOI, ROM, etc.), the regulatory interpretation of outcomes for focused diagnoses, and their impact on reimbursement and quality reporting for the organization. Assists in developing educational materials as needed.
Demonstrates knowledge of applicable regulatory standards/requirements by applying them accurately when providing guidance to customers. Accurately applies knowledge during record review activities.
Supports ad-hoc reviews or data collection activities for focused or special research studies conducted within the organization.
Teamwork/Customer Relation Responsibilities
Establishes effective working relationships with cross-functional team(s)
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scientists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research... and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major teaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.