The Clinical Documentation Specialist (CDS) provides clinically based concurrent and retrospective review of inpatient medical records to evaluate the documentation of acute care services. Includes facilitation of appropriate physician documentation of care to accurately reflect patient severity of illness and risk of mortality. Improves the overall quality and completeness of clinical documentation by working closely with providers and the application of coding guidelines, evidence-based knowledge, analysis, in-depth review, interpretation, identification of opportunities, communication, and consistent follow-up and evaluation of concurrent and retrospective (as required) medical record documentation.

Essential Duties:

• Identifies his/her respective service line(s) admissions in the CDI software/tool; and prioritizes reviews by age and payer. Completes his/her assignments by the end of the day
• Conducts new inpatient admissions reviews and proper working DRG assignment within 2 working days.
• Conducts follow up reviews and respective working DRG updates at least every 2 working days.
• Achieves a physician response rate of 100% through CDI education and interaction with physicians, identifying non-responders and intervening as necessary. Follows the query escalation process when no response.
• Identifies opportunities to improve documentation through physician query generation. Practice the mnemonic 'MEAT' (Monitored, Evaluated, Assessed or Treated) for building compliant and non-leading CDI queries. Applies evidence-based clinical criteria for clinical validation of diagnoses
• Utilizes the CDI software properly for tracking of CDI metrics and to assure compliance: documentation of pertinent clinical findings, compliant/non-leading queries, completion of all the required fields for data integrity and professional communication with coders and other staff members
• Directs a proper and complete CDI-Coding reconciliation process to accurate capture the complexity of the patients. Performs retrospective reviews and queries when necessary.
• Performs other related duties as assigned.

Required Qualifications:

• Req High school or equivalent
• Req Specialized/technical training Graduate of an accredited school of registered nursing and/or foreign medical graduate.

• Req 2 years Clinical documentation improvement experience.
• Req 3 years Clinical experience in an acute care setting.

• Req Demonstrates knowledge of ICD10-CM & PCS with respective coding guidelines & regulations for coding and reporting.
• Req Proficient on Inpatient Prospective Payment System (IPPS) documentation requirements for proper APR and MS DRGs assignment.
• Req Care delivery documentation systems and related medical record documentation.
• Req Strong broad based clinical knowledge and understanding of pathology/physiology of disease processes.
• Req Excellent written and verbal communication skills.
• Req Excellent critical thinking skills.
• Req Excellent interpersonal skills to build effective partnering relationships with physicians, nurses, and hospital staff.
• Req Working knowledge of inpatient admission criteria.
• Req Ability to work independently in a time oriented environment.

Preferred Qualifications:

• Pref Working knowledge of Medicare reimbursement system and coding structures.

Required Licenses/Certifications:

• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)
• Req Registered Nurse - RN (CA Board of Registered Nursing) OR Foreign Medical Graduate. (or valid state of residence Registered Nurse license for out-of-state employees [working remotely])
• Req Certification - Job Relevant Certified Clinical Documentation Specialist (CCDS); OR Certified Documentation Improvement Practitioner (CDIP)

The hourly rate range for this position is $46.00 - $76.07. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate's work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.