About the Department

Riverside University Health System-Medical Center has an opportunity for an Inpatient Clinical Documentation Improvement Specialist. Clinical Documentation Improvement (CDI) Specialists review medical record documentation to assure completeness, clarity, accuracy, and overall quality in accordance with Coding and Clinical Documentation Improvement goals. This classification is responsible for concurrent clinical documentation review, with an emphasis on completeness and accuracy of healthcare provider documentation related to types of medical services provided and the level of patient illness severity throughout hospital admission/discharge.

The CDI Specialist is experienced in clinical documentation review and capable of implementing methods of improving the accuracy, specificity, and completeness of patient-care documentation. The major role of a CDI Specialist is to serve as an institutional subject matter expert and as a resource for interpretation and application of coding rules and regulations; and, when necessary, write physician queries to obtain additional documentation or clarification. The incumbent provides guidance to physicians, clinicians, and coders regarding documentation requirements. A CDI Specialist is expected to possess an in-depth understanding of the substantive contents of a medical record, including extensive knowledge of a wide variety of specialized medical terminology, as well as medical diagnosis, treatment plans, and protocols.

Ideal candidates will have a strong understanding of PSI and HAC metrics, and the ability to ensure accurate documentation and coding that appropriately reflects patient acuity and quality outcomes in an acute care environment.

These positions have either a Monday-Friday or a Tuesday-Saturday, 9/80, hybrid in-person/remote schedule. Occasional travel will be required, as incumbents will rotate through the main hospital campus to provide CDI support and resources to clinical staff. During initial training and departmental onboarding, incumbents will work on-site full-time

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 is the only Pediatric ICU in the region. Can you see yourself here? For more information on RUHS-Medical Center, please visit ruhealth.org

Position 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 as a registered nurse in an acute care hospital. One year of inpatient CDI experience strongly preferred.

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, health information technology or a related field to the assignment. (Additional qualifying experience may substitute for the required education on the basis of one year of full-time experience equaling 30 semester or 45 quarter units of the required education).

Experience: Four years of professional coding and abstracting medical records in a healthcare setting. One year of inpatient CDI experience strongly preferred.

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. One year of inpatient CDI experience strongly preferred.

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.

ALL OPTIONS
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.

Other Qualifications

This recruitment is open to all applicants.

For additional information about this recruitment contact:
Angela Levinson
951-955-5562 or [email protected]

Benefits

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. Effective July 1, 2023 employee contributions are 7.25% and will increase to 7.75% effective July 1, 2024.

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 [email protected] 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:

Employees contribute to State Disability Insurance (SDI), which provides wage replacement benefits for individuals who are unable to work due to non-work-related illness, injury, or pregnancy. SDI also includes Paid Family Leave Benefits. The wage replacement rate is determined by current law, offering 60-70% of the wages earned during the SDI eligibility period.

Additionally, employees receive employer-paid Long-Term Disability Benefits, which cover 66.67% of pre-disability earnings, up to a maximum of $10,000 per month. There is a 365-day waiting period before these benefits become active. Employees may coordinate these benefits with other available leave balances to receive up to 100% of their regular pay.

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.

Supplemental Questions

Do you have a Bachelor's degree in nursing and at least three years of Registered Nurse experience in an acute care hospital and hold a valid CA RN license?

What is the highest level of education you have completed from an accredited college or university with coursework in health information management, health information technology or in a field related to the assignment?

No education or less than a year of education.
One year but less than two years of education.
Two years but less than three years of education, or completion of an Associate's degree.
Three years but less than four years of education.
Four years of education, no bachelor's degree.
Bachelor's degree.
Master's degree.
Doctorate.

Do you have a 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.

How many years of experience do you have coding and abstracting medical records in a healthcare setting?

None - less than one year of experience
One year but less than two
Two years but less than three.
Three years but less than four.
Four years but less than five.
Five years but less than six.
Six years but less than seven.
Seven years but less than eight.
Eight years or more experience coding and abstracting medical records.

Do you possess a Doctor of Medicine degree from the US or another country AND have at least one year of experience performing clinical documentation improvement in a healthcare setting?

Do you have experience utilizing EPIC and 3M Clinical Documentation Integrity Services

Do you have INPATIENT CDI experience?

Required Question

Agency Information

Employer: County of Riverside
Address: County Admin. Center P.O. Box 1569

4080 Lemon St., 7th floor

Riverside, California, 92502-1569
Phone: Contact Recruiter for Job Information
Website: http://www.rc-hr.com