CHA Hollywood Presbyterian Medical Center

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Inpatient Coder

at CHA Hollywood Presbyterian Medical Center

Posted: 9/29/2019
Job Reference #: 1631

Job Description

  • Job LocationsUS-CA-Los Angeles
    Job ID
    # of Openings
    Business / Administrative / Clerical
    Per Diem
  • Overview

    CHA Hollywood Presbyterian Medical Center

    CHA Hollywood Presbyterian Medical Center (HPMC) is an acute care facility that has been caring for the Hollywood community and surrounding areas since 1924. The hospital is committed to serving local multicultural communities with quality medical and nursing care. With more than 500 physicians representing virtually every specialty, HPMC strives to distinguish itself as a leading healthcare provider, recognized for providing quality, innovative care in a compassionate manner.

    HPMC is part of a global healthcare enterprise which owns and operates general hospitals throughout Korea, numerous fertility and research centers in the U.S. and Korea including CHA Fertility Center, a medical university, and CHAUM (a premier anti-aging life center).

    The Clinical Documentation Specialist is responsible conducting clinically based concurrent and retrospective reviews of inpatient medical records. This review is to evaluate that the clinical documentation is reflective of quality of care outcomes and reimbursement compliance for acute care services provided. The CDS will work closely with the medical staff to facilitate appropriate clinical documentation of patient care. Other responsibilities include conducting documentation for inpatient admission criteria, initial and extended-stay concurrent reviews on all selected admissions and documenting findings.

    Professional Requirements

    Position Summary:

    • Understands and is able to incorporate hospital philosophies into the department’s operational plan and goals, and assures staff members understand philosophies.
    • Demonstrates expertise in the clinical documentation, serving as a resource, and participates in problem-solving opportunities.
    • Contributes ongoing department information, sharing and promoting knowledge and skill development.
    • Comprehends and adheres to industry standards and regulatory requirements: including, but not limited to, TJC, HFAP, CMS, local regulations, HIPAA, medical staff regulations, and hospital policies.
    • Demonstrates knowledge of resource management plans in an effort to decrease resource consumption, while adequately maintaining effective operations.
    • Demonstrates working knowledge of information systems related to job duties.
    • Possesses an awareness of reimbursement processes, including how different payers use the coded data to determine reimbursement. Aware of Medicare reimbursement methodology for inpatient services as it pertains to clinical documentation and coding.
    • Possesses an awareness of hospital processes, understanding inter-department relationships, promoting collaborative effort and consideration prior to instituting changes, deletions or additions of processes.
    • Proficiency in utilization of computer based tools in retrieving and maintaining inpatient census data, coding and audit tracking.
    • Reviews inpatient medical records for identified payor populations (i.e., Medicare, etc.) as directed on admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation.
    • Ensures that clinical documentation reflects the level of service rendered to patients is complete, accurate and compliant with the regulations of the Center for Medicare and Medicaid Services.
    • Utilizes both clinical and coding knowledge to obtain appropriate documentation through extensive interaction with physicians, nursing, other patient caregivers and Health Information Management staff.
    • Performs initial inpatient charts reviews for documentation of inpatient admission criteria and assign working DRG within 24 hours of admission, on the working days.
    • Manages the concurrent medical record review for clinical documentation improvement throughout the hospital. Identifies physician documentation issues/omissions/discrepancies and assists physicians with improving documentation in the medical record.
    • Regularly participates in scheduled case management and hospitalist meetings and actively exchanges information pertaining to clinical documentation, plan of care affecting coding and reimbursement.
    • Maintains up to date working DRG and has clear strategies to effectuate improved quality of clinical documentation for all the select cases.
    • Assists in the development of diagnosis/DRG specific queries to aid physicians with proper and precise documentation.
    • Facilitates the appropriate clinical documentation to ensure that the intensity of services and level of acuity of the patient is accurately reflected in the medical record. Ensures abnormal findings are addressed, and the patient’s past medical history of conditions is appropriately documented.
    • Effectively utilizes documentation improvement communication tools
    • Utilizes the encoder software to determine the working DRG and communicates daily with the HIM coding staff.
    • Resolves inconsistent, conflicting and/or ambiguous documentation through the physician query process.
    • Follows up with the physicians to get resolution of all queries prior to patient’s discharge.
    • Takes responsibility and assists coders in follow-up on queries and clarifications to physicians done retrospectively post patient discharge.
    • Performs audits on the encoder software in order to facilitate ongoing auditing, monitoring and corrective action within the Clinical Documentation Improvement (CDI) process
    • Works with health information management coding staff, physicians and financial services with regards to payment denials, medical necessity and documentation issues. Instructs staff on proper documentation in the medical record.
    • Reviews audit inpatient claims with medical necessity denials looking for patterns by service or by the ordering physician. Follow-up in improving clinical documentation to reduce such denials.
    • Maintains detailed Case Mix Index (CMI) reports for performance evaluation of CDI process.
    • Maintains DRG assignment mismatch report of differences in DRG assignment by CDS and coders and provides feedback to supervising the Manager or Director for performance evaluation of CDI process.
    • On an ongoing basis educates all members of the patient care team on documentation guidelines. Develops educational materials to inform Medical Staff and Nursing Staff regarding to update on the clinical documentation requirements.
    • Actively participates and assists Performance Improvement Department in improving clinical documentation for compliance in quality of care measures (esp. Medicare CORE Measures) for specific charts
    • Performs all other duties as assigned or required.


    Minimum Education:

    • Graduate of an accredited Medical, PA or Nursing program required.
    • Preferred Education:
    • ECFMG Certificate preferred.

    Minimum Work Experience and Qualifications:

    • One year of clinical experience in acute care setting.
    • Minimum of two years’ experience with ICD-9 and CPT coding in an acute care setting.
    • Basic computer experience required.
    • Use of an encoder software product for code assignment in an acute care setting required
    • Excellent written and verbal communication skills. Excellent critical thinking skills.
    • Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.
    • Ability to work independently in a time-oriented environment.
    • Computer literacy and familiarity with the operation of basic office equipment
    • Preferred Work Experience and Qualifications:
    • Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm preferred
    • Required Licensure, Certification, Registration or Designation:

    Preferred Work Experience and Qualifications:

    • Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm preferred

    Required Licensure, Certification, Registration or Designation:


    Disclaimer, Compliance and Service Language:

    DISCLAIMER: The above statements are intended to describe the general nature and level of work being performed by incumbents assigned to this job. This is not intended to be an exhaustive list of all the responsibilities, duties and skills required. The incumbent may be expected to perform other duties as assigned.

    COMPLIANCE & INTEGRITY: Consistently supports compliance and the Hollywood Presbyterian Medical Center's Code of Conduct by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licensure requirements (if applicable), and Hollywood Presbyterian Medical Center's policies and procedures.

    Models and reinforces ethical behavior in self and others in accordance to the Code of Conduct; adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty; shows consistency in words and actions; follows through on commitments. All Directors, Managers and Supervisors are accountable for communication, implementation, enforcement, monitoring and oversight of compliance policies and practices in their departments.

    SERVICE & QUALITY: In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Hollywood Presbyterian Medical Center, as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our patients, and to purchasers, contracted providers and vendors.

    WORKPLACE SAFETY: In addition to defined working conditions and physical requirements, employees are accountable for working safely; following established policies & procedures; utilizing all designated protective personal equipment (PPE) and/or safety equipment assigned for task; and reporting all injuries and hazards to their supervisor immediately. Supervisors and Managers are accountable for ensuring the safety performance of employees; applying consistent practices in compliance with federal, state and local regulations; providing guidance to maintain a safe and healthy work environment.