Clinical Documentation Specialist Per Diem Day Shift

Job description

Job Summary: The Clinical Documentation Specialist plays a critical role in ensuring the accuracy and completeness of patient medical records. They review and analyze clinical documentation to ensure it meets regulatory and quality standards. Actively and consistently contributes to department operations and communications, behaves in a manner consistent with the mission, vision, and values of Pipeline Health, upholding standards of AIDET (Acknowledge, Introduce, Duration, Explanation, Thank you) patient communication. Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act. Essential Functions: - Review and analyze physician documentation, including progress notes, discharge summaries, and operative reports. - Identify and query missing or inaccurate information with physicians and other healthcare providers. - Assign appropriate ICD-10-CM and CPT codes to diagnoses and procedures. - Ensure documentation complies with regulatory requirements, including HIPAA and The Joint Commission standards. - Participate in clinical documentation impr...