Clinical Documentation Improvement Specialist

Are you a detail-oriented, analytical, and passionate individual looking for a challenging and rewarding career in the healthcare industry? Look no further! Universal Health Services is seeking a Clinical Documentation Improvement Specialist to join our dynamic team. In this role, you will play a crucial role in ensuring accurate and comprehensive clinical documentation to improve patient care and drive reimbursement. If you have a strong clinical background, exceptional communication skills, and a desire to make a significant impact in healthcare, we want to hear from you. Join us in our mission to provide high-quality, compassionate care to our patients and make a difference in their lives.

1. Review and analyze clinical documentation for accuracy, completeness, and compliance with coding and billing guidelines.
2. Collaborate with healthcare providers to identify and resolve documentation deficiencies and ensure accurate representation of patient acuity, severity of illness, and risk of mortality.
3. Conduct concurrent and retrospective chart reviews to identify opportunities for improvement in clinical documentation.
4. Educate and train healthcare providers on proper documentation practices and coding guidelines.
5. Utilize coding and classification systems to assign appropriate diagnostic and procedural codes.
6. Monitor and track documentation improvement metrics and report findings to leadership.
7. Stay up-to-date with changes in regulations and guidelines related to clinical documentation and coding.
8. Participate in interdisciplinary team meetings to discuss and address documentation-related issues.
9. Collaborate with coding and revenue cycle teams to ensure accurate and timely reimbursement.
10. Maintain confidentiality and adhere to ethical standards in handling patient information and documentation.
11. Assist with training and onboarding of new clinical documentation improvement staff.
12. Conduct regular audits to ensure compliance with coding and documentation guidelines.
13. Proactively identify and address areas for improvement in the documentation process.
14. Serve as a resource and subject matter expert on clinical documentation improvement for the organization.
15. Uphold the mission and values of the organization and promote a culture of quality and continuous improvement in clinical documentation.

According to JobzMall, the average salary range for a Clinical Documentation Improvement Specialist in Palmdale, CA, USA is $65,000 to $95,000 per year. This may vary depending on factors such as experience, education, and employer.

Universal Health Services, Inc. (UHS) is one of the largest and most respected providers of hospital and healthcare services in the nation with more than 90,000 employees dedicated to improving people’s lives and transforming the delivery of healthcare. Through its subsidiaries, the company operates 26 Acute Care hospitals, 328 Behavioral Health inpatient facilities, and 42 outpatient facilities and ambulatory care centers in 37 states in the U.S., Washington, D.C., Puerto Rico and the United Kingdom. UHS also offers health insurance plans through Prominence Health Plan, and manages a network of physicians through Independence Physician Management.