The Clinical Documentation Integrity Program Specialist II facilitates accurate, complete, and consistent clinical documentation within the inpatient health record to support reporting of high-quality healthcare data and coding. Core Competencies Assesses patients’ clinical conditions and risks compared to physicians’ documentation in accordance with regulatory and documentation standards using applicable coding conventions, rules, and guidelines. Uses data analysis to determine patient populations for targeted improvement efforts. Demonstrates knowledge of clinical conditions and procedures related to documentation integrity to support accurate reporting of diagnoses and procedures, severity of illness, and risk of mortality. Obtains additional documentation from physicians or providers for clarification when information is conflicting or incomplete. Reviews and assesses medical records within 24-48 hours of admission, including physician documentation, labs, radiology, and other provider notes. Utilizes software for documentation and tracking of reviews and clarifications. Collaborates with Medical Staff and other clinicians to address documentation issues and provide education on documentation requirements. Participates in evaluating and improving the CDI program, including development of educational materials and strategies. Partners with coding professionals to ensure accurate documentation supporting severity of illness and DRG assignment. Participates in ongoing evaluation and development of the Clinical Documentation Improvement Plan and educational strategies. Maintains productivity and quality standards as per policy. Department Specific Competencies Manages multiple projects and adapts to changing priorities. Engages in continuing education to enhance professional practice. Demonstrates organizational skills and attention to detail. Participates in continuous improvement initiatives. Education Bachelor's degree in Healthcare or related discipline; advanced degrees in Nursing, Medicine, HIM/Coding preferred. Experience Minimum of three years in medical/surgical acute care nursing or a Medical Degree with clinical practice experience. Alternatively, three years of acute inpatient coding with certification (CCDS or CDIP). License / Certification Requirements Certifications such as CCDS or CDIP required. Compensation Range $51.34 - $85.78 per hour #J-18808-Ljbffr Torrance Memorial Medical Center
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