Careers - VEP Healthcare



  • VEP Healthcare
  • 1001 Galaxy Way, Ste 400
  • Concord, CA 94520

  • Phone: 925-225-5837

Clinical Documentation Improvement Specialist
Los Angeles, CA

Job Summary:
The Clinical Documentation Improvement Specialist reviews, evaluates and assesses medical records of patients by looking for: specificity of an illness, accuracy of the clinician's documentation, coding requirements, and documentation of important medical details, in order to ensure the overall quality and completeness of clinical documentation of the patient medical record, and to ensure it is in compliance with government and other regulations. Works on problems of moderate to diverse scope requiring some interpretation of policies and guidelines. Applies working knowledge of the techniques, principles, theories and concepts to complete routine and non-routine assignments.
This position works away from the VEP Healthcare Corporate Office.  The preferred location for the CDIS is in the greater Los Angeles area.  The first 2-4 months of this position will be spent receiving additional education and training on existing documentation feedback processes currently in place, while supporting the existing program.
Essential Job Functions:
  • Evaluates and assesses medical records of patients: looks for specificity of an illness, the accuracy of the clinician's documentation, coding requirements and documentation of important medical details to ensure the overall quality and completeness of clinical documentation of the patient medical record.
  • Analyzes and interprets medical records and clinical documentation and formulates appropriate physician queries.
  • Reviews quality of medical record and communicates when conflicting data are found. Conveys deficiencies to the healthcare provider for more information to resolve the conflict.
  • Provides documentation feedback to providers in a one-on-one, small group, or larger formal lecture/presentation format.
  • Keeps abreast of regulatory changes related to documentation and coding and communicates these changes to appropriate staff.
  • Follows documentation guidelines and legal requirements to ensure compliance with federal and state regulatory bodies.
  • Acts as a liaison between the clinical providers and the independent third-party coding vendors to identify clinicians for additional documentation feedback.
  • Works collaboratively with physicians and coding vendor to ensure that clinical information in the medical record is present and accurate so that the appropriate clinical diagnosis and level of severity is captured for the level of service rendered to all patients.
  • Performs other job-related duties as assigned.
  • Frequent travel to sites is required, approximately 40% of time will be spent at clinical sites.
  • Familiarity with MS Office Suite of products, including ability to review and manipulate Excel spreadsheets, and to prepare PowerPoint presentations
 Education and Work Experience Requirements:
  • Three years Registered Nursing experience in Emergency Department setting:  Preferred
  • Three years experience as Certified Professional Medical Coder:  Preferred
  • Certified Clinical Documentation Specialist (CCDS) and /or Certified Documentation Improvement Practitioner (CDIP):  Preferred
  • Occassional lifting of up to 20 lbs required
  • Frequent sitting required

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Apply for the Clinical Documentation Improvement Specialist position

1001 Galaxy Way, Suite 400, Concord, CA 94520 | Phone: (925) 225-5837 | Main Fax: (925) 225-5838

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