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Clinical Documentation Specialist - Health Information Servi

Hawaii Pacific Health

Aiea, HI
Job Code:
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Job Details

Job ID: 7075
Job Title: Clinical Documentation Specialist - Health Information Servi
Location: Pali Momi Medical Center, Aiea, HI

Pali Momi Medical Center overlooks majestic Pearl Harbor on the island of O‘ahu. With 116 beds and more than 390 physicians on its medical staff, Pali Momi has delivered many medical firsts to the community, including West O‘ahu’s only interventional cardiac catheterization unit for the detection and treatment of heart disease, a fully integrated minimally invasive surgical suite, CT scan and MRI services, emergency services, a Women’s Center and the state’s first Retina Center. Pali Momi is the only facility in Hawai‘i that utilizes a team triage approach in its Emergency Room, where patients are promptly evaluated by an emergency physician. For five consecutive years, the American Heart Association has recognized the hospital with its Gold Award for excellence in the treatment of coronary artery disease and its Gold Plus Award for Heart Failure, making it one of only 7 in the nation to receive this distinction.

Health Information Services (HIS) processes patient medical records and releases health information to patients, physicians, and other outside facilities for treatment, payment, or review. HIS is the custodian and gatekeeper for privacy of the organization’s medical records and also generates the coding procedures for data collection, research, and reimbursement. With the widespread computerization of health records and other information sources, including hospital administration functions and health human resources information, health informatics and health information technology are being increasingly used in the health care sector.

If you are highly organized and detail-oriented, you can help to manage our clinical records according to the highest ethical standards of patient privacy and security. As the Clinical Documentation Specialist, you will work to improve the overall quality of medical record documentation to ensure compliance with Medicare and Medicaid (CMS) guidelines and to expedite reimbursement. You will use both clinical and coding knowledge to obtain documentation through extensive interaction with physicians, nursing, other patient caregivers, Case Management and Health Information Management staff. You will also ensure that the clinical information used in measuring and reporting outcomes is complete, accurate, and that reimbursement is received for services rendered to patients with DRG-based payers. You will also educate members of the patient care team on documentation guidelines. We are looking for someone with exceptional organizational and communication skills, attention to detail and protocol and a commitment to delivering the highest quality health care to Hawai‘i’s people.




Location: Pali Momi Medical Center, Aiea, HI


Work Schedule: Day - 8 Hours


Work Type: Full Time Regular 


FTE: 1.000000


Bargaining Unit: Non-Bargaining


Exempt: Yes


Minimum Qualifications: Current Hawai‘i Registered Nurse License. Bachelor’s degree and/or equivalent combination of education, training and experience. Three (3) years acute care nursing experience. Must obtain Clinical Documentation Improvement (CDI) certification through a nationally recognized CDI Specialist program within one (1) year of hire.

Preferred Qualifications: Current CDI certification. Knowledge of InterQual, Milliman or other nationally recognized Utilization Management criteria. Knowledge of DRGs or inpatient International Classification of Diseases 10th edition (ICD-10) CM coding experience. Knowledge of health regulatory environment.




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