Job Description

Description: Must reside in Northern California! Job Summary: This position requires a high level of professional clinical knowledge and knowledge of coding guidelines and documentation requirements to identify and query for documentation improvement. This documentation clarification improves overall patient quality, as well as maximizes the capture and reflection of the acuity of the patient.Through essential and effective communication with physicians and ancillary clinical providers, accurate classification of the severity of illness and risk of mortality level of the patient is achieved. This position works within a multidisciplinary professional team to achieve desired documentation outcomes at the facilitylevel. Essential Responsibilities: Effective and efficient inpatient concurrent medical record review for accurate and completedocumentation, within an electronic medical record environment. Reviews clinical cases in collaboration with medical coding staff and physicians, to identify additional diagnoses that impact severity of illness/risk of mortality indicators for each patient. Manages and prioritizes numerous cases on a daily basis. Manages cases at the facility level, using flexibility to provide coverage for any NCAL facility, based on staffing need, as determined by census, on a daily basis. Facilitates appropriate clinical documentation to support diagnosis capture and to ensure the level of service rendered to all patients is accurately recorded and reflected. Provides expert analysis of the medical record documentation for signs/symptoms/clinical indicators, to identify potential primary and secondary diagnoses and complications existing within each patient case. Formulates and distributes physician documentation clarification queries following coding guidelines and all applicable compliance standards. Creates, monitors and tracks verbal and written queries, responses and their impact; producing reports as required. Identifies documentation trends, and areas of opportunity for physician education regarding documentation. Conducts data and root cause analysis, provides feedback and shares findings on the analysis to regional CDI Leadership. Collaborates with TPMG contacts and CDI staff and Leadership in the development of programs which provide alignment with education for internal customers to support clinical documentation guidelines. Leads special projects/committees that contribute to the development of an effective CDI program.Collaborates and communicates with local HIM staff and local HIM leadership to ensure accurate documentation capture. Effectively communicates with local coding staff regarding query responses, to assist with the efficiency and completeness of the medical record of the post-discharge physician query process. Provides feedback and serves as clinical expert resource to CDIC QA staff. Provides expert advice to CDI Regional Managers to develop, implement and monitor policies and procedures that support organizational goals and business objectives related to the CDI Program. Adheres to organizational standards to promote a cooperative work environment by utilizing professional communication skills. Collaborates effectively with coding professionals, nursing and clinical experts, ancillary services, physicians and administration. Establishes, fosters and maintains effective working relationships with the local and regional staff/teams/leadership. Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees. Basic Qualifications: Experience Minimum four (4) years of clinical nursing experience (i.e. Inpatient, clinical documenatation, discharge planning or case management). Education Bachelors degree OR four (4) years of experience in a directly related field (i.e. Inpatient, clinical documentation, discharge planning or case management). High School Diploma or General Education Development (GED) required. License, Certification, Registration Physician Assistant License (California) OR Doctor of Medicine License (Foreign Country) OR Doctor of Medicine License (California) OR Registered Nurse License (California) Additional Requirements: RN, NP, PA or MD may qualify depending on background and experience. Ability to utilize clinical knowledge to interpret physician documentation and clinical indicators to identify potential opportunities for documentation clarification/specification. Demonstrated ability to work in an autonomous work environment. Strong interpersonal, communication (verbal, non-verbal, and listening skills). Demonstrated ability to conduct and interpret quantitative/qualitative analysis. Proven leadership skills in project management and/or consulting. Must exhibit efficiency, collaboration, candor, and openness and results orientation. Understanding of Adult Learning Theory. Application of Adult Learning Theory to orientation and training of new hires. Understanding of how to perform and achieve success in a data driven environment. Excellent time management and prioritization skills. Must be able to work in a Labor/Management Partnership environment. Preferred Qualifications: Experience working with an electronic health record (Epic) Experience working with 3M Encoder Knowledge of and experience with Heirarchical Condition Categories (HCCs) Clinical experience in Intensive Care patient care experience preferred. Minimum 2 years Clinical Documentation Integrity or Improvement experience Minimum 3 yrs inpatient clinical patient care experience Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Professional (CDIP) preferred. Experience with chart review and/or auditing preferred (i.e. utilization management, case management, discharge planning, etc.). Experience/working knowledge of Coding Classification Systems (current ICD-CM classification, MS-DRGs, HCCs) and payment methodologies preferred. Clinician Documentation Integrity/mprovement (CDI) experience preferred. Certified Clinical Documentation Specialist(CCDS) OR Certified Documentation Improvement Practioner (CDIP) Certification preferred. Bachelors degree of Science in Nursing (BSN), Master of Science in Nursing (MSN), Master of Science (MS) with Nurse Practioner or Physician Assistant License, MBS (Bachelor of Science in Medicine), or Doctorate of Medicine (MD) preferred. Primary Location: California,Oakland,Ordway Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 08:00 AM Working Hours End: 05:00 PM Job Schedule: Full-time Job Type: Standard Worker Location: Remote Employee Status: Regular Employee Group/Union Affiliation: NUE-NCAL-09|NUE|Non Union Employee Job Level: Individual Contributor Department: Oakland Reg - 1800 Harrison - Clinical Doc lmprov Codng Svc - 0208 Pay Range: $147200 - $190410 / year Kaiser Permanente strives to offer a market competitive total rewards package and is committed to pay equity and transparency. The posted pay range is based on possible base salaries for the role and does not reflect the full value of our total rewards package. Actual base pay determined at offer will be based on labor market data and a candidate's years of relevant work experience, education, certifications, skills, and geographic location. Travel: No Remote: Work location is the remote workplace (from home) within KP authorized states. Worker location must align with Kaiser Permanente's Authorized States policy. At Kaiser Permanente, equity, inclusion and diversity are inextricably linked to our mission, and we aim to make it a part of everything we do. We know that having a diverse and inclusive workforce makes Kaiser Permanente a better place to receive health care, a more supportive partner in our communities we serve, and a more fulfilling place to work. Working at Kaiser Permanente means that you agree to and abide by our commitment to equity and our expectation that we all work together to create an inclusive work environment focused on a sense of belonging and wellbeing. Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status. Submit Interest Kaiser Permanente

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