Health Care

applicants

The Clinical Documentation Specialist (CDS) facilitates modifications to clinical documentation through concurrent interaction with physicians and other members of the health care team to support that appropriate clinical severity is captured for the level of service rendered to all inpatients.ESSENTIAL DUTIES AND RESPONSIBILITIES (not all inclusive)§ The CDS will provide daily clinical evaluation of the medical record including physician and clinical documentation, lab results, diagnostic information and treatment plans.§ Responsible for day-to-day evaluation of documentation by the Medical Staff and healthcare team in accordance with the hospital’s designated clinical documentation policies and procedures.§ Communicates with physicians, face to face or via clinical documentation inquiry forms, regarding missing, unclear or conflicting medical record documentation to clarify the information, obtain needed documentation, present opportunities, and educate for appropriate identification of severity of illness.§ Communicates with appropriate healthcare team members to ensure accurate and complete documentation is in the medical record.§ Demonstrates an understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix, secondary diagnosis, impact of procedures on the final DRG, and an ability to impart this knowledge to physicians and other members of the healthcare team.§ Gathers and analyzes information pertinent to documentation findings and outcomes.REQUIREMENTSMust have an active California State Registered Nursing License. Clinical expert with at least 2 years of recent inpatient experience. CCS or Coding experience is desirable. Bachelor of Science in Nursing preferred. RHIA/RHIT with 10 years of inpatient coding experience is preferred. Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting. Demonstrated adaptability and self-motivation by staying abreast of CMS rules and regulations and incorporating those changes into daily practice. Excellent verbal and written communication skills. Must have knowledge of federal, state and private payer regulations.Salary/Wage: $NegotiableStatus: Full-timeShift: Days