Senior Clinical Documentation Consultant

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 facility level.

• 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.