Reviews a moderate caseload of medical and health records to improve the accuracy and completeness of clinical documentation and assigns medical codes and DRGs to support accurate diagnosis capture.
Supports the clinical documentation improvement/integrity (CDI) program by helping resolve documentation issues, conducting audits, and documenting non-compliance in accordance with coding guidelines and federal regulations.
Collaborates with others on staff training and education related to medical review, coding, quality standards, and documentation requirements for diagnosis capture.
Works independently on clinical documentation reviews, contributes to process improvements, supports documentation clarification query resolution, and helps maintain compliance with regulatory requirements.
Minimum qualifications:
- At least 2 years of experience in an inpatient acute care or clinical setting
- Foreign Medical Graduate (FMG) degree
- Clinical Document Specialist Certificate, Certified Coding Specialist (CCS), or Certified Documentation Integrity Specialist required at hire
Preferred qualifications:
- Certified Clinical Documentation Specialist (CCDS)
- Certified Documentation Improvement Practitioner (CDIP)
- Certified Coding Specialist (CCS)
- Certified Coding Specialist Physician-based (CCS-P)
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- 3 years of experience using Epic or another EMR system
Location
Oakland, California, US
Employment Type
Full-time
Experience Level
Senior
Salary Range
$133,100 - $172,150
Remote work allowed
No
Posted
3 weeks ago