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Clinical Documentation Specialist

Spectraforce

Fountain Valley, California


12 hours ago

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Clinical Documentation Specialist
Spectraforce
Fountain Valley, California

12 hours ago

Job Description

**Remote Role****Applications 360, 3M and Iodine highly desired**Purpose Statement / Position SummaryThis position is responsible for initiating and completing the concurrent review of medical records to ensure the information documented accurately reflects the patients severity of illness, clinical treatment, risk of mortality, and quality and intensity of care. Reviews include verifying that clinical conditions are documented in diagnostic format to ensure appropriate reporting, identifying query opportunities to clarify or validate clinical conditions, assigning principal and secondary diagnoses and/or procedures for appropriate designation of DRG and LOS, and identifying quality indicators and codes that contribute to reportable quality metrics and compliance standards. Essential Functions and Responsibilities of the Job 1. Computer, internet, and word processing experience required.2. Excellent verbal and written communication skills.3. Collaborative interaction and effective education skills with the medical staff and ancillary departments to collegially discuss clinical aspects of care is vital.4. Ability to perform accurate patient chart review analysis and data collection.5. Ability to prioritize essential functions and multitask utilizing multiple resources and applications (including but not limited to: 3M 360, EPIC, Outlook, Iodine, Microsoft Teams, Zoom, SharePoint)6. Ability to demonstrate integrated knowledge of job specific competencies.7. Follow company and department policies, procedures, and directives.8. Maintain HIPAA and patient confidentiality at all times.9. Ability to work autonomously and productively in a remote work environment while adhering to all company security policies and remote-work agreement. 10. Ability to interact in a positive and constructive manner., Education: EducationMD, BS or higher in healthcare related field, or licensed coder (CCS) with strong clinical knowledge base and background.Clinical licensure (RN, PA, NP, MD, or FMD) and/or Coding certification (CCS) required. CCDS and/or CDIP certification preferred., Languages: English 
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At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 28.00/daily.